Medicaid & Medicare

Live Video

The most predominantly reimbursed form of telehealth modality is live video, with Medicare and every state offering some type of live video reimbursement in their Medicaid program. However, what and how it is reimbursed varies widely. The most common restrictions include restricting it to certain specialty types, service codes, types of providers or limiting the location of the patient to specific originating sites.

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Federal

Last updated 07/17/2024

POLICY

The Secretary shall pay for telehealth services that are …

POLICY

The Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

We pay for specific Medicare Part B services that a physician or practitioner provides via 2-way, interactive technology (or telehealth). Telehealth substitutes for an in-person visit, and generally involves 2-way, interactive technology that permits communication between the practitioner and patient.

During the COVID-19 public health emergency (PHE), we used emergency waiver and other regulatory authorities so you could provide more services to your patients via telehealth. Section 4113 of the Consolidated Appropriations Act, 2023 extended many of these flexibilities through December 31, 2024, and made some of them permanent.

Billing and Payment

Bill covered telehealth to your Medicare Administrative Contractor (MAC). They pay you the appropriate telehealth amount under the Physician Fee Schedule (PFS).
Submit professional telehealth claims using the appropriate CPT or HCPCS code.
If you performed telehealth through asynchronous telehealth, add the telehealth GQ modifier with the professional service CPT or HCPCS code. You’re certifying you collected and sent the asynchronous medical file at the distant site from a federal telemedicine demonstration conducted in Alaska or Hawaii.
Distant site practitioners billing telehealth under the CAH Optional Payment Method II must submit institutional claims using the GT modifier.
If you’re located in, and you reassigned your billing rights to, a CAH and elected the outpatient Optional Payment Method II, the CAH bills the MAC for telehealth. The payment is 80% of the PFS distant site facility amount for the distant site service.

Based on several telehealth-related provisions of the Consolidated Appropriations Act (CAA), 2023 and the
CY 2024 PFS final rule, we’re:

Temporarily expanding the scope of telehealth originating sites for services provided via telehealth to include any site in the U.S. where the patient is at the time of the telehealth service, including a person’s home
Temporarily expanding the definition of telehealth practitioners to include qualified occupational therapists (OTs), physical therapists (PTs), speech-language pathologists (SLPs), and audiologists
Adding mental health counselors and marriage and family therapists as distant site practitioners for purposes of providing telehealth services
Continuing payment for telehealth services rural health clinics (RHCs) and federally qualified health centers (FQHCs) provided using the methodology established for those telehealth services during the PHE
Temporarily delaying the requirement for an in-person visit with the physician or practitioner within 6 months before initiating mental health telehealth services, and, again, at subsequent intervals as the Secretary determines appropriate, as well as similar requirements for RHCs, FQHCs, and hospital
outpatient departments (HOPDs)
Allowing teaching physicians to use audio or video real-time communications technology when the resident provides Medicare telehealth services in all residency training locations through the end of CY 2024
Temporarily removing frequency limitations in 2024 for:
- Subsequent inpatient visits
- Subsequent nursing facility visits
- Critical care consultation
Allowing hospitals of PT, OT, SLP, diabetes self-management training (DSMT) and medical nutrition therapy (MNT) services that remain on the Medicare Telehealth Services List to continue to bill for these services when provided remotely in the same way they’ve been during the PHE except that:
- For outpatient hospitals, patients’ homes no longer need to be registered as provider-based entities to allow for hospitals to bill for these services
- The 95 modifier is required on claims from all institutional providers, except for Critical Access Hospitals (CAHs) electing Method II, as soon as hospitals needing to do so can update their systems

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Apr. 2024, (Accessed Jul. 2024).

CY 2024 Physician Fee Schedule notes that section 4113 of Division FF, Title IV, Subtitle A of the Consolidated Appropriations Act, 2023 (CAA, 2023) (Pub. L. 117-328, December 29, 2022) extends the telehealth policies enacted in the Consolidated Appropriations Act, 2022 (CAA, 2022) (Pub. L. 117-103, March 15, 2022) through December 31, 2024, if the PHE ends prior to that date, as discussed in section II.D.c. of this final rule. These provisions included:

Temporarily removing the geographic and site requirements for the patient location at the time the telehealth interaction takes place
Temporarily allowing a more expansive list of eligible providers in Medicare to provide services via telehealth such as physical and occupational therapists and federally qualified health centers (FQHCs) and rural health clinics (RHCs)
Temporarily allowing some services to continue to be provided via audio-only
Temporarily suspending the in-person service requirement prior to the delivery of mental and behavioral services via telehealth or audio-only in cases where the geographic requirement does not apply, the service takes place in the home and the patient was not being treated for a substance use disorder

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Jul. 2024).

Requirements for mental health services furnished through telehealth (Delay of In-Person mental health requirement)

Payment may not be made under this paragraph for telehealth services furnished on or after January 1, 2025 (or, if later, the first day after the end of the emergency period described in section 1320b–5(g)(1)(B) of this title) by a physician or practitioner to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder unless such physician or practitioner furnishes an item or service in person, without the use of telehealth, for which payment is made under this subchapter (or would have been made under this subchapter if such individual were entitled to, or enrolled for, benefits under this subchapter at the time such item or service is furnished)—

within the 6-month period prior to the first time such physician or practitioner furnishes such a telehealth service to the eligible telehealth individual; and
during subsequent periods in which such physician or practitioner furnishes such telehealth services to the eligible telehealth individual, at such times as the Secretary determines appropriate.

These requirements do not apply to services:

Under this paragraph (with respect to telehealth services furnished to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder); or
under this subsection without application of this paragraph.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

When the PHE ends, can individuals continue to see providers virtually using telehealth?

Yes, in most cases. During the PHE, individuals with Medicare had broad access to telehealth services, including in their homes, without the geographic or location limits that usually apply. These waivers were included as provisions of The Consolidated Appropriations Act, 2023, which extended many telehealth flexibilities through December 31, 2024, such as:

People with Medicare can access telehealth services in any geographic area in the United States, rather than only in rural areas.
People with Medicare can stay in their homes for telehealth visits that Medicare pays for rather than traveling to a health care facility.
Certain telehealth visits can be delivered using audio-only technology (such as a telephone) if someone is unable to use both audio and video (such as a smartphone or computer).
However, if an individual receives routine home care via telehealth under the hospice benefit, this flexibility will end at the end of the PHE.
MA plans may offer additional telehealth benefits. Individuals in an MA plan should check with their plan about coverage for telehealth services. Additionally, after December 31, 2024, when these flexibilities expire, some ACOs may offer telehealth services that allow primary care doctors to care for patients without an in-person visit, no matter where they live.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Jul. 2024).

During the PHE, the Secretary has been using the waiver authority under section 1135 of the Act to create flexibilities in the requirements of section 1834(m) of the Act and 42 CFR § 410.78 for use of interactive telecommunications systems to furnish telehealth services. This allows clinicians to furnish more services to beneficiaries via telehealth so that they can take care of their patients while mitigating the risk of the spread of the virus.

During the public health emergency, all beneficiaries across the country have been able to receive Medicare telehealth and other communications technology-based services wherever they are located. Additionally, after the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for some of these flexibilities through December 31, 2024. During the public health emergency, all beneficiaries across the country have been able to receive Medicare telehealth and other communications technology-based services wherever they are located. Additionally, after the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for some of these flexibilities through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, 11/6/23, (Accessed Jul. 2024).

In addition to the requirement for the in-person visit mentioned above in statute, CMS will also require there to be an in-person, non-telehealth service within 12 months of each mental health telehealth service. However, if the patient and practitioner agree that the benefits of an in-person, non-telehealth service within 12 months of the mental health telehealth service are outweighed by risks and burdens associated with an in-person service, and the basis for that decision is documented in the patient’s medical record, the in-person visit requirement will not apply for that particular 12-month period. CMS will allow a clinician’s colleague in the same subspecialty in the same group to furnish the in-person, non-telehealth service to the beneficiary if the original practitioner is unavailable. [Implementation delayed until January 1, 2025.]

See eligible providers section for additional information for federally qualified health centers (FQHCs) and rural health clinics (RHCs).

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 63, (Accessed Jul. 2024).

Background

Section 223 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) – Revision of Medicare Reimbursement for Telehealth Services amended §1834 of the Act to provide for an expansion of Medicare payment for telehealth services.

Effective October 1, 2001, coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system. Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as a metropolitan statistical area (MSA). Additionally, Federal telemedicine demonstration projects as of December 31, 2000, may serve as the originating site regardless of geographic location.

An interactive telecommunications system is required as a condition of payment; however, BIPA does allow the use of asynchronous “store and forward” technology in
delivering these services when the originating site is a Federal telemedicine demonstration program in Alaska or Hawaii. BIPA does not require that a practitioner present the patient for interactive telehealth services.

With regard to payment amount, BIPA specified that payment for the professional service performed by the distant site practitioner (i.e., where the expert physician or practitioner is physically located at time of telemedicine encounter) is equal to what would have been paid without the use of telemedicine. Distant site practitioners include only a physician as described in §1861(r) (go to the link and select the applicable title) of the Act and a medical practitioner as described in §1842(b)(18)(C) (go to the link and select the applicable title) of the Act. BIPA also expanded payment under Medicare to include a $20 originating site facility fee (location of beneficiary).

Previously, the Balanced Budget Act of 1997 (BBA) limited the scope of Medicare telehealth coverage to consultation services and the implementing regulation prohibited the use of an asynchronous, ‘store and forward’ telecommunications system. BBA 1997 also required the professional fee to be shared between the referring and consulting practitioners, and prohibited Medicare payment for facility fees and line charges associated with the telemedicine encounter.

BIPA required that Medicare Part B (Supplementary Medical Insurance) pay for this expansion of telehealth services beginning with services furnished on October 1, 2001.

Section 149 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended §1834 of the Act to add certain entities as originating sites for payment of telehealth services. Effective for services furnished on or after January 1, 2009, eligible originating sites include a hospital-based or critical access hospital-based renal dialysis center (including satellites); a skilled nursing facility (as defined in §1819(a) of the Act); and a community mental health center (as defined in §1861(ff)(3)(B) of the Act). MIPPA also amended§1888(e)(2)(A)(ii) of the Act to exclude telehealth services furnished under §1834(m)(4)(C)(ii)(VII) from the consolidated billing provisions of the skilled nursing facility prospective payment system (SNF PPS).

NOTE: MIPPA did not add independent renal dialysis facilities as originating sites for payment of telehealth services.

The telehealth provisions authorized by §1834(m) of the Act are implemented in 42 CFR 410.78 and 414.65.

Conditions of Payment

For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 141-142, 151, (Accessed Jul. 2024).

* The US Health and Human Services Administration maintains a website that summarizes Medicare policies.

ELIGIBLE SERVICES/SPECIALTIES

Temporary Policy Ending Dec. 31, 2024

CMS has waived the requirements of section 1834(m)(4)(E) of the Act and 42 CFR § 410.78 (b)(2), which specify the types of practitioners who may bill for their services when furnished as Medicare telehealth services from a distant site. The waiver of these requirements expands the types of health care professionals who can furnish distant site telehealth services to include all those who are eligible to bill Medicare for their professional services. As a result, a broader range of practitioners, such as physical therapists, occupational therapists, and speech language pathologists can use telehealth to provide many Medicare services. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for this flexibility through December 31, 2024.

Additionally, we modified the process to add services to the Medicare Telehealth Services List during the PHE, allowing us to consider adding appropriate services on a sub-regulatory basis, as they were requested, as practitioners were actively learning how to use telehealth. A complete list of all Medicare telehealth services can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

After the PHE ends, we will resume consideration of changes to the Medicare Telehealth Services List exclusively through notice and comment rulemaking.

See factsheet for Medicare telehealth service list.

These services will remain on the Medicare Telehealth Services List and will be available through the end of CY 2023, and we anticipate addressing updates to the Medicare Telehealth Services List for CY 2024 and beyond through our established processes as part of the CY 2024 Physician Fee Schedule proposed and final rules.

Using section 1135 waiver authority, on an interim basis during the PHE, we removed the frequency restrictions for the following listed codes furnished via Medicare telehealth. These restrictions were established through rulemaking and implemented through systems edits:

A subsequent inpatient visit could be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days (CPT codes 99231-99233).
A subsequent skilled nursing facility visit could be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 14 days (CPT codes 99307- 99310).
Critical care consult codes could be furnished to a Medicare beneficiary by telehealth, without the limitation that the telehealth visit is once per day (HCPCS codes G0508- G0509).

We have received a number of inquiries from interested parties regarding temporarily continuing our suspension of these frequency limitations beyond the end of the PHE, specifically our requirement that CPT codes 99231-99233 may only be furnished via Medicare telehealth once every 3 days, and our requirement that CPT codes 99307-99309 may only be furnished via Medicare telehealth once every 14 days. We are exercising enforcement discretion and will not consider these frequency limitations through December 31, 2023, as we anticipate considering our policy further through our rulemaking process.

Medicare patients with end-stage renal disease (ESRD) who are on home dialysis must receive a face-to-face visit, without the use of telehealth, at least monthly in the case of the initial three months of home dialysis and at least once every three consecutive months after the initial three months. We used section 1135 waiver authority during the PHE to allow these visits to be furnished as telehealth services. This will expire at the end of the COVID-19 public health emergency.

To the extent that a National Coverage Determination (NCD) or Local Coverage Determination (LCD) would otherwise require an in-person, face-to-face visit for evaluations and assessments, we used section 1135 waiver authority to remove those requirements so that these services can be furnished via telehealth during the public health emergency. This will expire at the end of the COVID-19 public health emergency.

Opioid Treatment Programs (OTPs): During the PHE, patient counseling and therapy services have been provided by telephone in cases where two-way interactive audio-video communication technology is not available to the beneficiary, and all other applicable requirements are met. This flexibility has been made permanent for OTPs in the CY 2022 PFS final rule. During the PHE, periodic assessments have been conducted via two-way interactive audio-video communication technology and may have been provided by telephone, only in cases where the beneficiary has not had access to two-way interactive audio-video communication technology and all other applicable requirements have been met.

SOURCE: Centers for Medicare and Medicaid Services, Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, 11/6/23, (Accessed Jul 2024).

Temporarily removing frequency limitations in 2024 for:

Subsequent inpatient visits
Subsequent nursing facility visits
Critical care consultation

SOURCE: CMS Medicare Learning Network (MLN) Telehealth Services, MLN 901705 (April 2024). (Accessed Jul. 2024).

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Jul. 2024).

Section 3706 of The CARES Act allowed for face-to-face encounters for purposes of patient recertification for the Medicare hospice benefit can now be conducted via telehealth (i.e., two-way audio-video telecommunications technology that allows for real-time interaction between the hospice physician/hospice nurse practitioner and the patient). This statutory change will expire on December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Hospice: CMS Flexibilities to Fight COVID-19, 5/10/23, (Accessed Jul. 2024).

Permanent Policy

Subject to paragraph (8), the term “telehealth service” means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes 99241–99275, 99201–99215, 90804–90809, and 90862 (and as subsequently modified by the Secretary)), and any additional service specified by the Secretary.

The Secretary shall establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes), as appropriate, to those specified in clause (i) for authorized payment under paragraph (1).

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

The use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services. The various services and corresponding current procedure terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are listed on the CMS website at www.cms.gov/Medicare/MedicareGeneral-Information/Telehealth/

NOTE: Beginning January 1, 2010, CMS eliminated the use of all consultation codes, except for inpatient telehealth consultation G-codes. CMS no longer recognizes office/outpatient or inpatient consultation CPT codes for payment of office/outpatient or inpatient visits. Instead, physicians and practitioners are instructed to bill a new or established patient office/outpatient visit CPT code or appropriate hospital or nursing facility care code, as appropriate to the particular patient, for all office/outpatient or inpatient visits.

Telehealth Consultation Services, Emergency Department or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits

A consultation service is an evaluation and management (E/M) service furnished to evaluate and possibly treat a patient’s problem(s). It can involve an opinion, advice, recommendation, suggestion, direction, or counsel from a physician or qualified nonphysician practitioner (NPP) at the request of another physician or appropriate source. Section 1834(m) of the Social Security Act includes “professional consultations” in the definition of telehealth services. Inpatient or emergency department consultations furnished via telehealth can facilitate the provision of certain services and/or medical expertise that might not otherwise be available to a patient located at an originating site. The use of a telecommunications system may substitute for an in-person encounter for emergency department or initial and follow-up inpatient consultations.

Medicare A/B MACs (B) pay for reasonable and medically necessary inpatient or emergency department telehealth consultation services furnished to beneficiaries in hospitals or SNFs when all of the following criteria for the use of a consultation code are met:

An inpatient or emergency department consultation service is distinguished from other inpatient or emergency department evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices;
A request for an inpatient or emergency department telehealth consultation from an appropriate source and the need for an inpatient or emergency department telehealth consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record; and
After the inpatient or emergency department telehealth consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.

The intent of an inpatient or emergency department telehealth consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.

Unlike inpatient or emergency department telehealth consultations, the majority of subsequent inpatient hospital, emergency department and nursing facility care services require in-person visits to facilitate the comprehensive, coordinated, and personal care that medically volatile, acutely ill patients require on an ongoing basis.

Subsequent hospital care services are limited to one telehealth visit every 3 days. Subsequent nursing facility care services are limited to one telehealth visit every 30 days. Beginning with dates of service on and after January 1, 2021, the limit for nursing facility care services is one telehealth visit every 14 days.

Telehealth Consultation Services, Emergency Department or Initial Inpatient Defined

Emergency department or initial inpatient telehealth consultations are furnished to beneficiaries in hospitals or SNFs via telehealth at the request of the physician of record, the attending physician, or another appropriate source. The physician or practitioner who furnishes the emergency department or initial inpatient consultation via telehealth cannot be the physician of record or the attending physician, and the emergency department or initial inpatient telehealth consultation would be distinct from the care provided by the physician of record or the attending physician. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs. Emergency department or initial inpatient telehealth consultations are subject to the criteria for emergency department or initial inpatient telehealth consultation services, as described in section 190.3.1 of this chapter.

Payment for emergency department or initial inpatient telehealth consultations includes all consultation related services furnished before, during, and after communicating with the patient via telehealth. Pre-service activities would include, but would not be limited to, reviewing patient data (for example, diagnostic and imaging studies, interim labwork) and communicating with other professionals or family members. Intra-service activities must include the three key elements described below for each procedure code. Post-service activities would include, but would not be limited to, completing medical records or other documentation and communicating results of the consultation and further care plans to other health care professionals. No additional E/M service could be billed for work related to an emergency department or initial inpatient telehealth consultation.

Emergency department or initial inpatient telehealth consultations could be provided at various levels of complexity. (see manual for details).

Although emergency department or initial inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service.

Follow-Up Inpatient Telehealth Consultations Defined

Follow-up inpatient telehealth consultations are furnished to beneficiaries in hospitals or SNFs via telehealth to follow up on an initial consultation, or subsequent consultative visits requested by the attending physician. The initial inpatient consultation may have been provided in-person or via telehealth.

Follow-up inpatient telehealth consultations include monitoring progress, recommending management modifications, or advising on a new plan of care in response to changes in the patient’s status or no changes on the consulted health issue. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs.

The physician or practitioner who furnishes the inpatient follow-up consultation via telehealth cannot be the physician of record or the attending physician, and the follow-up inpatient consultation would be distinct from the follow-up care provided by the physician of record or the attending physician. If a physician consultant has initiated treatment at an initial consultation and participates thereafter in the patient’s ongoing care management, such care would not be included in the definition of a follow-up inpatient consultation. Follow-up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services, as described in section 190.3.1 of this chapter.

Payment for follow-up inpatient telehealth consultations includes all consultation related services furnished before, during, and after communicating with the patient via telehealth. Pre-service activities would include, but would not be limited to, reviewing patient data (for example, diagnostic and imaging studies, interim labwork) and communicating with other professionals or family members. Intra-service activities must include at least two of the three key elements described below for each procedure code. Post-service activities would include, but would not be limited to, completing medical records or other documentation and communicating results of the consultation and further care plans to other health care professionals. No additional evaluation and management service could be billed for work related to a follow-up inpatient telehealth consultation.

Follow-up inpatient telehealth consultations could be provided at various levels of complexity (see manual for details).

Although follow-up inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service.

ESRD-Related Services as a Telehealth Service

The ESRD-related services included in the monthly capitation payment (MCP) with 2 or 3 visits per month and ESRD-related services with 4 or more visits per month may be paid as Medicare telehealth services. However, at least 1 visit must be furnished face-to-face “hands on” to examine the vascular access site by a physician, clinical nurse specialist, nurse practitioner, or physician assistant. An interactive audio and video telecommunications system may be used for providing additional visits required under the 2-to-3 visit MCP and the 4-or-more visit MCP. The medical record must indicate that at least one of the visits was furnished face-to-face “hands on” by a physician, clinical nurse specialist, nurse practitioner, or physician assistant.

Clinical Criteria: The visit, including a clinical examination of the vascular access site, must be conducted face-to-face “hands on” by a physician, clinical nurse specialist, nurse practitioner or physician’s assistant. For additional visits, the physician or practitioner at the distant site is required, at a minimum, to use an interactive audio and video telecommunications system that allows the physician or practitioner to provide medical management services for a maintenance dialysis beneficiary. For example, an ESRD-related visit conducted via telecommunications system must permit the physician or practitioner at the distant site to perform an assessment of whether the dialysis is working effectively and whether the patient is tolerating the procedure well (physiologically and psychologically). During this assessment, the physician or practitioner at the distant site must be able to determine whether alteration in any aspect of the beneficiary’s prescription is indicated, due to such changes as the estimate of the patient’s dry weight.

Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services

Subsequent hospital care services are limited to one telehealth visit every 3 days. The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow-up inpatient telehealth consultations using the applicable HCPCS G-codes.

Similarly, subsequent nursing facility care services are limited to one telehealth visit every 30 days. Beginning with dates of service on and after January 1, 2021, the limit for nursing facility care services is one telehealth visit every 14 days. Furthermore, subsequent nursing facility care services reported for a Federally-mandated periodic visit under 42 CFR 483.40(c) may not be furnished through telehealth. The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow-up inpatient telehealth consultations using the applicable HCPCS G-codes.

Inpatient telehealth consultations are furnished to beneficiaries in hospitals or skilled nursing facilities via telehealth at the request of the physician of record, the attending physician, or another appropriate source. The physician or practitioner who furnishes the initial inpatient consultation via telehealth cannot be the physician or practitioner of record or the attending physician or practitioner, and the initial inpatient telehealth consultation would be distinct from the care provided by the physician or practitioner of record or the attending physician or practitioner. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs. Initial and follow-up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services, as described in section 190.3 of this chapter.

Diabetes Self-Management Training as a Telehealth Service

Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefit’s initial training must be furnished in-person to allow for effective injection training. Because injection training is not always clinically indicated, we are revising this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow-up training to be furnished via telehealth in those cases when injection training is not applicable. The in-person injection training, when provided, may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the – GT or –GQ modifier with HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.

Payment for Telehealth for Individuals with Acute Stroke

Section 50325 of the Bipartisan Budget Act of 2018 amended section 1834(m) of the Act by adding a new paragraph (6) that provides special rules for telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke (acute stroke telehealth services), as determined by the Secretary. Specifically, section 1834(m)(6)(A) of the Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke telehealth services can be furnished. Section 1834(m)(6)(B) of the Act specifies that acute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determined appropriate by the Secretary, in addition to the current eligible telehealth originating sites. Section 1834(m)(6)(C) of the Act limits payment of an originating site facility fee to acute stroke telehealth services furnished in sites that meet the usual telehealth restrictions under section 1834(m)(4)(C) of the Act. These are identified in Section 190.1 of this chapter.

Effective for claims with dates of service on and after January 1, 2019, contractors shall accept new informational HCPCS modifier G0 (G zero), to be used to identify Telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke. Modifier G0 is valid for all:

Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X); or
Telehealth originating site facility fee, billed with HCPCS code Q3014

Editing of Telehealth Claims

Medicare telehealth services (as listed in section 190.3) are billed with POS 02 and 10. The contractor shall approve covered telehealth services if the physician or practitioner is licensed under State law to provide the service. Contractors must familiarize themselves with licensure provisions of States for which they process claims and disallow telehealth services furnished by physicians or practitioners who are not authorized to furnish the applicable telehealth service under State law. For example, if a nurse practitioner is not licensed to provide individual psychotherapy under State law, he or she would not be permitted to receive payment for individual psychotherapy under Medicare. The contractor shall install edits to ensure that only properly licensed physicians and practitioners are paid for covered telehealth services.

Contractors shall deny telehealth services if the physician or practitioner is not eligible to bill for them.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 145, (Accessed Jul. 2024).

ESRD Treatment – Temporary Policy

§494.90(b)(4): CMS has modified the requirement that the ESRD dialysis facility ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist, or physician’s assistant providing ESRD care at least monthly, and periodically while the hemodialysis patient is receiving in-facility dialysis. CMS has been waiving the requirement for a monthly in-person visit if the patient is considered stable and also recommends exercising telehealth flexibilities; e.g., phone calls, to ensure patient safety. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension of telehealth flexibility through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, End Stage Renal Disease (ESRD) Facilities: CMS Flexibilities to Fight COVID-19, 5/10/23, (Accessed Jul. 2024).

Since telehealth dialysis services are limited to renal dialysis services for home dialysis patients telehealth related to renal dialysis services is not available for beneficiaries with AKI.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 11: End Stage Renal Disease (ESRD), 3/1/19, pg. 60, (Accessed Jul. 2024).

Medicare Part B pays for covered telehealth services included on the telehealth list when furnished by an interactive telecommunications system if the following conditions are met, except that for the duration of the Public Health Emergency as defined in § 400.200 of this chapter, Medicare Part B pays for office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management and end stage renal disease related services included in the monthly capitation payment furnished by an interactive telecommunications system if the following conditions are met.

A clinical psychologist and a clinical social worker, a marriage and family therapist (MFT), and a mental health counselor (MHC) may bill and receive payment for individual psychotherapy via a telecommunications system, but may not seek payment for medical evaluation and management services.

The physician visits required under § 483.40(c) of this title may not be furnished as telehealth services.

The distant site practitioner who reports the DSMT services may bill and receive payment when a professional furnishes injection training for an insulin-dependent patient using interactive telecommunications technology when such training is included as part of the DSMT plan of care referenced at § 410.141(b)(2).

SOURCE: 42 CFR Sec. 410.78 (Accessed Jul. 2024).

Process for adding or deleting services. Except as otherwise provided in this paragraph (f), changes to the list of Medicare telehealth services are made through the annual physician fee schedule rulemaking process. During the Public Health Emergency, as defined in § 400.200 of this chapter, we will use a subregulatory process to modify the services included on the Medicare telehealth list during the Public Health Emergency, taking into consideration infection control, patient safety, and other public health concerns resulting from the emergency. CMS maintains the list of services that are Medicare telehealth services under this section, including the current HCPCS codes that describe the services on the CMS website.

SOURCE: 42 CFR Sec. 410.78 (Accessed Jul. 2024).

List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth is available on the CMS website. Find the complete List of Telehealth Services by downloading the ZIP and opening the Excel or text files.

SOURCE: CMS Telehealth List Year, Updated 11/13/2023. (Accessed Jul. 2024).

Through December 31, 2024:

You may use telehealth to conduct hospice care eligibility recertification
For behavioral or mental telehealth, you don’t have to conduct an in-person visit within 6 months of the initial telehealth visit or annually thereafter
We’ve extended the Acute Hospital Care at Home Program, which heavily relies on telehealth for hospitals to provide inpatient services, including routine services, outside the hospital

CY 2024, we’re adding new codes to the list of Medicare telehealth services, including:

CPT codes 0591T – 0593T for health and well-being coaching services, which we’re adding on a temporary basis
HCPCS code G0136 for Social Determinants of Health Risk Assessment, which we’re adding on a permanent basis

Based on several telehealth-related provisions of the Consolidated Appropriations Act (CAA), 2023 and the CY 2024 PFS final rule, we’re: …

Removing frequency limitations in 2024 for:
- Subsequent inpatient visits
- Subsequent nursing facility visits
- Critical care consultation

Starting January 1, 2023, you may voluntarily report the use of telehealth technology in providing home health (HH) services on HH payment claims. See MLN Matters Article MM12805 for more information.

Starting July 1, 2023, you must include on HH claims:

G0320: Home health services you furnish using synchronous telehealth you render via real-time audio video telehealth
G0321: Home health services you furnish using synchronous telehealth you render via telephone or another real-time, interactive, audio-only telehealth
G0322: The collection of physiologic data the patient digitally stores or transmits to the HH agency

See fact sheet for additional details.

CY 2024, we’re adding new codes to the list of Medicare telehealth services, including:

CPT codes 0591T – 0593T for health and well-being coaching services, which we’re adding on a temporary basis
HCPCS code G0136 for Social Determinants of Health Risk Assessment, which we’re adding on a permanent basis

Based on several telehealth-related provisions of the Consolidated Appropriations Act (CAA), 2023 and the CY 2024 PFS final rule, we’re: …

Temporarily delaying the requirement for an in-person visit with the physician or practitioner within 6 months before initiating mental health telehealth services, and, again, at subsequent intervals as the Secretary determines appropriate, as well as similar requirements for RHCs, FQHCs, and hospital outpatient departments (HOPDs)
Temporarily removing frequency limitations in 2024 for:
- Subsequent inpatient visits
- Subsequent nursing facility visits
- Critical care consultation

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Apr. 2024, (Accessed Jul. 2024).

Communication Technology-Based Services (CTBS)

CMS makes separate payment for brief communication technology-based services. This includes ‘brief communication technology-based service, e.g. virtual check-in’ by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion). The code (G2012) allows real-time audio-only telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission. The service is limited to established patients.

Interprofessional consultations are reimbursable by CMS as part of their CTBS services (CPT codes include 99451, 99452, 99446, 99447, 99448, and 99449). Cost sharing will apply. These interprofessional services may be billed only by practitioners that can bill Medicare independently for evaluation and management services. Includes telephone and internet assessments.

CTBS services are not regarded by CMS as telehealth.

ELIGIBLE PROVIDERS

Temporary Policy – Ends Dec. 31, 2024

The term “practitioner” has the meaning given that term in section 1395u(b)(18)(C) of this title and, in the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, for the period beginning on the first day after the end of such emergency period and ending on December 31, 2024, shall include a qualified occupational therapist (as such term is used in section 1395x(g) of this title), a qualified physical therapist (as such term is used in section 1395x(p) of this title), a qualified speech-language pathologist (as defined in section 1395x(ll)(4)(A) of this title), and a qualified audiologist (as defined in section 1395x(ll)(4)(B)).

…

In the case that such emergency period ends before December 31, 2024, during the period beginning on the first day after the end of such emergency period and ending on December 31, 2024—

the Secretary shall pay for telehealth services that are furnished via a telecommunications system by a Federally qualified health center or a rural health clinic to an eligible telehealth individual enrolled under this part notwithstanding that the Federally qualified health center or rural clinic providing the telehealth service is not at the same location as the beneficiary;
the amount of payment to a Federally qualified health center or rural health clinic that serves as a distant site for such a telehealth service shall be determined under subparagraph (B); and
for purposes of this subsection—
- the term “distant site” includes a Federally qualified health center or rural health clinic that furnishes a telehealth service to an eligible telehealth individual; and
- the term “telehealth services” includes a rural health clinic service or Federally qualified health center service that is furnished using telehealth to the extent that payment codes corresponding to services identified by the Secretary under clause (i) or (ii) of paragraph (4)(F) are listed on the corresponding claim for such rural health clinic service or Federally qualified health center service.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

Reporting Home Address: During the PHE, CMS allowed practitioners to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location. Even though the PHE is anticipated to end on May 11, 2023, the waiver will continue through December 31, 2024.

[Also listed in Teaching Hospital COVID Factsheet]

SOURCE: Centers for Medicare and Medicaid Services, Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, 11/6/23, (Accessed Jul. 2024).

Through the end of CY 2023, hospital and other providers of physical therapy, occupational therapy, speech-language pathology, diabetes self-management training and medical nutrition therapy services that remain on the telehealth list, can continue to bill for these services when furnished remotely in the same way they have been during the PHE, except that beneficiaries’ homes will no longer need to be registered as provider-based departments of the hospital to allow for hospitals to bill for these services. We note that we are exercising enforcement discretion in reviewing the telehealth practitioner status of the clinical staff personally providing any part of a remotely furnished DSMT service, so long as the practitioner is otherwise qualified to provide the service.

SOURCE: Centers for Medicare and Medicaid Services, Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs: CMS Flexibilities to Fight COVID-19, 6/26/23, (Accessed Jul. 2024).

Application of Teaching Physician Regulations: Under current rules, Medicare payment is made for services furnished by a teaching physician involving residents only if the physician is physically present for the key portion of the service or procedure, and immediately available to furnish services during the entire procedure, where applicable. During the COVID-19 PHE, teaching physicians may use audio/video real time communications technology to interact with the resident through virtual means, which would meet the requirement that they be present for the key portion of the service, including when the teaching physician involves the resident in furnishing Medicare Telehealth services. After the PHE, CMS is exercising enforcement discretion to allow teaching physicians in all teaching settings to be present virtually, through audio/video real-time communications technology, for purposes of billing under the PFS for services they furnish involving resident physicians. We are exercising this enforcement discretion through December 31, 2023, as we anticipate considering our policy for services involving teaching physicians and residents further through our rulemaking process. These flexibilities do not apply in the case of surgical, high risk, interventional, or other complex procedures, services performed through an endoscope, and anesthesia services. This allows teaching hospitals to maximize their workforce to safely take care of patients.

SOURCE: Centers for Medicare and Medicaid Services, Teaching Hospitals, Teaching Physicians and Medical Residents, 11/6/23, (Accessed Jul. 2024).

Home Health Agencies (HHAs) can provide more services to beneficiaries using telecommunications technology within the 30-day period of care, as long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. We acknowledge that the use of such technology may result in changes to the frequency or types of in-person visits outlined on existing or new plans of care. Telecommunications technology can include, for example: remote patient monitoring; telephone calls (audio only and TTY); and two-way audio-video technology that allows for real-time interaction between the clinician and patient. This provision is permanent beyond the COVID-19 PHE. Home health services furnished using telecommunication systems are required to be included on the home health claim beginning July 1, 2023.

The required face-to-face encounter for home health can be conducted via telehealth (i.e., 2-way audio-video telecommunications technology that allows for real-time interaction between the physician/allowed practitioner and the patient) when the patient is at home. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for the flexibility to allow the home to be an originating site through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Home Health Agencies, CMS Flexibilities to Fight COVID-19, 5/10/23, (Accessed Jul. 2024).

Beginning on or after January 1, 2023, HHAs may voluntarily report the use of telecommunications technology in the provision of home health services on claims. This information is required on home health claims beginning on July 1, 2023. HHAs shall submit the use of telecommunications technology when furnishing home health services, on the home health claim via three G-codes.

G0320: home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system
G0321: home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system
G0322: the collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e., remote patient monitoring).

HHAs shall submit services furnished via telecommunications technology in line item detail and each service must be reported as a separately dated line under the appropriate revenue code for each discipline furnishing the service. Two occurrences of G0320 or G0321 on the same day for the same revenue code shall be reported as separate line items.

Claims with no billable visits are not submitted to Medicare, including claims for billing periods where only telehealth services are provided.

Telehealth services with HCPCS codes G0320 or G0321 are reported with units of 1.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 10: Home Health Agency Billing, 10/19/23, pg. 61, (Accessed Jul. 2024).

At the end of the PHE, when can hospitals bill for:

The originating site facility fee (HCPCS code Q3014)?
The clinic visit (HCPCS code G0463)?
Remote mental health services (HCPCS codes C7900 – C7902)?

Following the anticipated end of the PHE (May 11, 2023):

Hospitals cannot bill for this code after the PHE unless the beneficiary is located within a hospital and the beneficiary receives a Medicare telehealth service from an eligible distant site practitioner. Only in these cases can the hospital would bill for the originating site facility fee (HCPCS code Q3014). See question 17 for additional details.
If the beneficiary is within a hospital and receives a hospital outpatient clinic visit (including a mental/behavioral health visit) from a practitioner in the same physical location, then the hospital would bill for the clinic visit (HCPCS code G0463).
If the beneficiary is in their home and receives a mental/behavioral health service from hospital staff through the use of telecommunications technology and no separate professional service can be billed, then the hospital would bill for the applicable HCPCS C-code describing this service (HCPCS codes C7900 – C7902).

Following the end of the PHE, can hospitals bill for outpatient physical therapy (PT), occupational therapy (OT), speech language pathology (SLP) services, Diabetes Self-Management Training (DSMT), or Medical Nutrition Therapy (MNT) provided to beneficiaries in their homes through telecommunication technology by hospital-employed staff?

In context of the end of the PHE, we have received a number of inquiries from interested parties regarding the expiration of this policy. We have reviewed all of the relevant guidance, including applicable billing instructions and external feedback, and recognize the confusion around these policies. We also recognize that the therapists and many of the other practitioners who provide these services remain on the list of distant site practitioners for Medicare telehealth services.

However, for DSMT services, we understand that some other types of hospital clinical staff, beyond those identified as eligible distant site practitioners for Medicare telehealth, can provide these services in some cases. To allow these services to continue to be furnished to patients in their home through telecommunication technology through the end of CY 2023, we are exercising enforcement discretion in reviewing the telehealth practitioner status of the clinical staff personally providing any part of a remotely furnished DSMT service, so long as the practitioner is otherwise qualified to provide the service. Through the end of CY 2023, PT, OT, SLP, DSMT, MNT providers should continue to bill for these services when furnished remotely in the same way they have been during the PHE.

Following the end of the PHE, can other facilities bill for outpatient physical therapy (PT), occupational therapy (OT), speech language pathology (SLP) services, Diabetes Self-Management Training (DSMT), or Medical Nutrition Therapy (MNT) provided to beneficiaries in their homes through telecommunication technology by their staff?

Similar to the questions we received regarding billing for outpatient therapy, DSMT, and MNT services in hospitals, in context of the end of the PHE, we have also received a number of inquiries from interested parties regarding the expiration of this policy as it relates to other facilities. We recognize that therapists and many of the other practitioners who provide these services remain on the list of distant site practitioners for Medicare telehealth services. PT, OT, SLP, DSMT, MNT providers should continue to bill for these telehealth services under the Medicare Physician Fee Schedule when furnished remotely in the same way they have been during the PHE.

Accordingly, outpatient therapy, DSMT, and MNT services furnished remotely by institutional providers of therapy services such as rehabilitation agencies and comprehensive outpatient rehabilitation facilities, not including those that are receiving payment under any

Part A payment systems (home health agencies (HHAs) and skilled nursing facilities (SNFs)), should continue to be furnished and billed the same way they have been during the PHE, which can include the use of telecommunications technology and when billed on institutional claims forms.

For HHAs, all services within a 30-day period of care are part of a bundled prospective payment. As was the case during the PHE, while CMS allows services to be furnished via a telecommunications system so long as the services are included in a beneficiary’s plan of care, these services cannot be considered a “visit” for purposes of patient eligibility or payment per Medicare law, nor can they substitute for a home visit as ordered on the plan of care. Medicare is requiring HHAs to report the use of telecommunications technology in providing home health services on home health payment claims on July 1, 2023, and HHAs may voluntarily report this information until that time.

For SNFs and inpatient rehabilitation facilities (IRFs), under Part A, CMS pays through a bundled payment for all covered Part A services. To the extent that therapy services furnished via telehealth or telecommunications technology are covered Part A services, then these services would be considered part of the bundled prospective payment system payment under Part A and such services would not be separately billable for those patients in a Part A covered SNF or IRF stay.

Again, Part B outpatient therapy, DSMT, and MNT services furnished remotely by institutional providers of therapy, should continue to be furnished and billed the same way they have been during the PHE, which can include the use of telecommunications technology.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Jul. 2024).

Inpatient Rehabilitation Facility (IRF) Flexibilities Issued on March 30, 2020

On March 30, 2020, CMS issued the interim final rule “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency” (CMS-1744-IFC). …

This interim final rule also revises the physician supervision requirement in 42 CFR § 412.622(a)(3)(iv) and § 412.29(e) to permit physician visits in the IRF required under these provisions to be conducted via telehealth to safeguard the health and safety of Medicare beneficiaries and the rehabilitation physicians treating them during the PHE. Contractors shall allow rehabilitation physicians to use telehealth services as defined in section 1834(m)(4)(F) of the Act to conduct the required 3 physician visits per week during the PHE for the COVID-19 pandemic.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 1: Inpatient Hospital Services Covered Under Part A, 8/6/21, pg. 40, (Accessed Jul. 2024).

Permanent Policy

Subject to paragraph (8), the Secretary shall pay to a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth individual an amount equal to the amount that such physician or practitioner would have been paid under this subchapter had such service been furnished without the use of a telecommunications system.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

The physician or practitioner at the distant site must be licensed to furnish the service under State law. The physician or practitioner at the distant site who is licensed under State law to furnish a covered telehealth service described in this section may bill, and receive payment for, the service when it is delivered via a telecommunications system.

The practitioner at the distant site is one of the following:

A physician
A nurse practitioner
Physician Assistant
A clinical nurse specialist
A nurse-midwife
A clinical psychologist
A clinical social worker
A registered dietitian or nutrition professional
A certified registered nurse anesthetist
Any distant site practitioner who can appropriately bill for diabetes self-management training services may do so on behalf of others who personally furnish the services as part of the DSMT entity.
A marriage and family therapist
A mental health counselor

Clinical psychologist and a clinical social worker, a marriage and family therapist (MFT), and a mental health counselor (MHC) may bill and receive payment for individual psychotherapy via a telecommunications system, but may not seek payment for medical evaluation and management services.

The physician visits required under § 483.40(c) of this title may not be furnished as telehealth services.

SOURCE: 42 CFR Sec. 410.78, (Accessed Jul. 2024).

A distant site is the location where a physician or practitioner provides telehealth. Before the COVID-19 PHE, only certain types of distant site providers could provide and get paid for telehealth. Through December 31, 2024, all providers who are eligible to bill Medicare for professional services can provide distant site telehealth

Based on several telehealth-related provisions of the Consolidated Appropriations Act (CAA), 2023 and the CY 2024 PFS final rule, we’re:

Temporarily expanding the definition of telehealth practitioners to include qualified occupational therapists (OTs), physical therapists (PTs), speech-language pathologists (SLPs), and audiologists
Adding mental health counselors and marriage and family therapists as distant site practitioners for purposes of providing telehealth services
Continuing payment for telehealth services rural health clinics (RHCs) and federally qualified health centers (FQHCs) provided using the methodology established for those telehealth services during the PHE
Temporarily delaying the requirement for an in-person visit with the physician or practitioner within 6 months before initiating mental health telehealth services, and, again, at subsequent intervals as the Secretary determines appropriate, as well as similar requirements for RHCs and FQHCs
Allowing teaching physicians to use audio or video real-time communications technology when the resident provides Medicare telehealth services in all residency training locations through the end of CY 2024
Allowing hospitals and other providers of PT, OT, SLP, diabetes self-management training (DSMT) and medical nutrition therapy (MNT) services that remain on the Medicare Telehealth Services List to continue to bill for these services when provided remotely in the same way they’ve been during the PHE and the remainder of CY 2023, except that:
- For outpatient hospitals, patients’ homes no longer need to be registered as provider-based entities to allow for hospitals to bill for these services
- The 95 modifier is required on claims from all providers, except for Critical Access Hospitals (CAHs) electing Method II, as soon as hospitals needing to do so can update their system

Temporarily removing frequency limitations in 2024 for:
- Subsequent inpatient visits
- Subsequent nursing facility visits
- Critical care consultation

Institutional Billing

Use modifier 95 when the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services provided via telehealth by qualified PTs, OTs, or SLPs employed by hospitals through December 31, 2024

See the Policy Overview section at the top for Professional Billing requirements.

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Apr. 2024, (Accessed Jul. 2024).

ESRD Services: The MCP physician, for example, the physician or practitioner who is responsible for the complete monthly assessment of the patient and establishes the patient’s plan of care, may use other physicians and practitioners to furnish ESRD-related visits through an interactive audio and video telecommunications system. The non-MCP physician or practitioner must have a relationship with the billing physician or practitioner such as a partner, employees of the same group practice or an employee of the MCP physician, for example, the non MCP physician or practitioner is either a W-2 employee or 1099 independent contractor. However, the physician or practitioner who is responsible for the complete monthly assessment and establishes the ESRD beneficiary’s plan of care should bill for the MCP in any given month.

A medical professional is not required to present the beneficiary to physician or practitioner at the distant site unless medically necessary. The decision of medical necessity will be made by the physician or practitioner located at the distant site.

The term “distant site” means the site where the physician or practitioner, providing the professional service, is located at the time the service is provided via a telecommunications system.

The payment amount for the professional service provided via a telecommunications system by the physician or practitioner at the distant site is equal to the current fee schedule amount for the service provided. Payment for an office visit, consultation, individual psychotherapy or pharmacologic management via a telecommunications system should be made at the same amount as when these services are furnished without the use of a telecommunications system. For Medicare payment to occur, the service must be within a practitioner’s scope of practice under State law. The beneficiary is responsible for any unmet deductible amount and applicable coinsurance.

As a condition of Medicare Part B payment for telehealth services, the physician or practitioner at the distant site must be licensed to provide the service under state law. When the physician or practitioner at the distant site is licensed under state law to provide a covered telehealth service (i.e., professional consultation, office and other outpatient visits, individual psychotherapy, and pharmacologic management) then he or she may bill for and receive payment for this service when delivered via a telecommunications system.

If the physician or practitioner at the distant site is located in a CAH that has elected Method II, and the physician or practitioner has reassigned his/her benefits to the CAH, the CAH bills its regular A/B/MAC (A) for the professional services provided at the distant site via a telecommunications system, in any of the revenue codes 096x, 097x or 098x. All requirements for billing distant site telehealth services apply.

Medicare Practitioners Who May Bill for Covered Telehealth Services are Listed Below (subject to State law)

Physician
Nurse practitioner
Physician assistant
Nurse-midwife
Clinical nurse specialist
Clinical psychologist*
Clinical social worker*
Registered dietitian or nutrition professional
Certified registered nurse anesthetist

*Clinical psychologists and clinical social workers cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for the following CPT codes: 90805, 90807, and 90809.

As specified in 42 CFR 410.141(e) and stated in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 300.2, individual and group DSMT services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 CFR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a physician, PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.

See manual for additional billing guidance.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 145, 152 (Accessed Jul. 2024).

Beginning January 1, 2024, MHCs and MFTs can provide and bill Medicare telehealth services. Exceptions to the in-person visit requirement require a clear justification documented in the patient’s medical record. Hospitals must also document that patients have a regular source of general medical care and can get any needed point-of-care testing, including vital sign monitoring and lab studies.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Learning Network Booklet 1986542, Medicare & Mental Health Coverage, Jan. 2024, (Accessed Jul. 2024).

After consideration of public comments, we are finalizing our proposal to add MFTs and MHCs as distant site practitioners for purposes of furnishing telehealth services. We are finalizing our proposed amendments to add MFTs and MHCs to the list of distant site practitioners in the telehealth regulation at § 410.78(b)(2)(xi),(xii).

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Jul. 2024.

CMS allows Opioid Treatment Programs (OTPs) to use two-way interactive audio-video communication technology, as clinically appropriate, in furnishing substance use counseling and individual and group therapy services. An intake add-on code by live video for the initiation of treatment with buprenorphine, when clinically appropriate and in compliance with other requirement was also added.

SOURCE: CY 2020 Final Physician Fee Schedule. CMS, p. 249, & CY 2023 Final Physician Fee Schedule, CMS, p. 1055, (Accessed Jul. 2024).

Communication Technology-Based Services

Payment for communication technology-based and remote evaluation services. For communication technology-based and remote evaluation services furnished on or after January 1, 2019, payment to RHCs and FQHCs is at the rate set for each of the RHC and FQHC payment codes for communication technology-based and remote evaluation services.

SOURCE: 42 CFR 405.2464 (Accessed Jul. 2024).

RHCs and FQHCs are not eligible for reimbursement of interprofessional consultation services, as only practitioners that can bill Medicare independently for evaluation and management services are eligible.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40, (Accessed Jul. 2024).

Medicare waives the RHC and FQHC face-to-face requirements when an RHC or FQHC furnishes these services to an RHC or FQHC patient. RHCs and FQHCs receive payment for communication technology-based services or remote evaluation services when an RHC or FQHC practitioner provides at least 5 minutes of communications-based technology or remote evaluation services to a patient who has been seen in the RHC or FQHC within the previous year.

RHCs and FQHCs may only bill for these services when the medical discussion or remote evaluation is for a condition not related to an RHC or FQHC service provided within the previous 7 days, and does not lead to an RHC or FQHC service within the next 24 hours or at the soonest available appointment, since in those situations, Medicare already pays for the services as part of the RHC or FQHC per-visit payment.

RHCs and FQHCs can bill G0511, G0512, and G0071 alone or with other payable services on an RHC or FQHC claim.

SOURCE: Medicare Learning Network Matters Factsheet, MM10843, Aug. 10, 2018, (Accessed Jul. 2024).

What are “virtual communication services” for RHCs and FQHCs?

In the 2019 Physician Fee Schedule (PFS) Final Rule, CMS finalized a policy that, effective January 1, 2019, RHCs and FQHCs can receive payment for virtual communication services when at least 5 minutes of communication technology-based or remote evaluation services are furnished by an RHC or FQHC practitioner to a patient who has had an RHC or FQHC billable visit within the previous year, and both of the following requirements are met:

The medical discussion or remote evaluation is for a condition not related to an RHC or FQHC service provided within the previous 7 days, and
The medical discussion or remote evaluation does not lead to an RHC or FQHC visit within the next 24 hours or at the soonest available appointment.

See FAQ for more details.

SOURCE: Virtual Communication Services RHCs and FQHCs FAQs, December 2018, (Accessed Jul. 2024).

Mental Health for FQHCs and RHCs

Revised definition of a ‘mental health visit’ to include encounters furnished through interactive, real-time telecommunications technology, but only when furnishing services for purposes of diagnosis, evaluation or treatment of a mental health disorder.

FQHCs and RHCs will be able to furnish mental health visits to include visits furnished using interactive, real-time telecommunications technology and RHCs and FQHCs can report and be paid for furnishing those visits in the same way they currently do when these services are furnished in-person. RHCs and FQHCs will be paid for mental health visits furnished via telecommunications technology at the same rate they are paid for in-person mental health visits (that is, the AIR or FQHC PPS).

There must be an in-person mental health service furnished within 6 months prior to the furnishing of the telecommunications service and that in general, there must be an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders. This applies only to patients receiving services at home. If the patient and practitioner consider the risks and burdens of an in-person service and agree that, on balance, these outweigh the benefits, and the practitioner documents the basis for that decision in the patient’s medical record, then the in-person visit requirement is not applicable for that 12-month period.

In person requirement delayed under Medicare until on or after January 1, 2025.

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 214-215 & delay in implementation in HR 2617 (2022 Session). (Accessed Jul. 2024).

RHCs and FQHCs can provide telecommunications for mental health visits using audio-video technology and audio-only technology. You may use audio-only technology in situations when your patient can’t access or doesn’t consent to use audio-video technology. You can report and get paid in the same way as in-person visits.

Audio-video visits: Use modifier 95 (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System).
Audio-only visits: Use new service-level modifier FQ or 93.

These in-person visit requirements apply only to a patient getting mental health visits via telecommunications at home:

There must be an in-person mental health visit 6 months before the telecommunications visit
In general, there must be an in-person mental health visit at least every 12 months while the patient is getting services from you via telecommunications to diagnose, evaluate, or treat mental health disorders

NOTE: Section 4113 of the Consolidated Appropriations Act (CAA), 2023, delayed the in-person visit requirements under Medicare for mental health visits that RHCs and FQHCs provide via telecommunications technology. For RHCs and FQHCs, we won’t require in-person visits until January 1, 2025.

CMS will allow for limited exceptions to the requirement for an in-person visit every 12 months based on patient circumstances in which the risks and burdens of an in-person visit may outweigh the benefit. These include, but aren’t limited to, when:

An in-person visit is likely to cause disruption in service delivery or has the potential to worsen the patient’s condition
The patient getting services is in partial or full remission and only needs maintenance level care
The clinician’s professional judgment says that the patient is clinically stable and that an in-person visit has the risk of worsening the patient’s condition, creating undue hardship on self or family
The patient is at risk of withdrawing from care that’s been effective in managing the illness

With proper documentation, the in-person visit requirement isn’t applicable for that 12-month period. You must document the circumstance in the patient’s medical record.

SOURCE: Mental Health Visits via Telecommunications for Rural Health Clinics and Federally Qualified Health Centers, MLN Matters SE22001, (May 23, 2023), (Accessed Jul. 2024).

A mental health visit is a medically-necessary face-to-face encounter between an RHC or FQHC patient and an RHC or FQHC practitioner during which time one or more RHC or FQHC mental health services are rendered. Effective January 1, 2022, a mental health visit is a face-to-face encounter or an encounter furnished using interactive, real-time, audio and video telecommunications technology or audio-only interactions in cases where the patient is not capable of, or does not consent to, the use of video technology for the purposes of diagnosis, evaluation or treatment of a mental health disorder.

The CAA, 2023 extends the telehealth policies of the CAA, 2022 through December 31, 2024 if the PHE ends prior to that date. The in-person visit requirements for mental health telehealth services and mental health visits furnished by RHCs and FQHCs begin on January 1, 2025 if the PHE ends prior to that date. There must be an in-person mental health service furnished within 6 months prior to the furnishing of the mental health service furnished via telecommunications and that an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reasons for this decision in the patient’s medical record.

RHCs and FQHCs are instructed to append modifier 95 (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System) in instances where the mental health visit was furnished using audio-video communication technology and to append modifier 93 (Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System) in cases where the service was furnished using audio-only communication.

Mental health services that qualify as stand-alone billable visits in an FQHC are listed on the FQHC center website, http://www.cms.gov/Center/Provider-Type/FederallyQualified-Health-Centers-FQHC- Center.html. Services furnished must be within the practitioner’s state scope of practice.

Medicare-covered mental health services furnished incident to an RHC or FQHC visit are included in the payment for a medically necessary mental health visit when an RHC or FQHC practitioner furnishes a mental health visit. Group mental health services do not meet the criteria for a one-one-one, face-to-face encounter in an FQHC or RHC.

A mental health service should be reported using a valid HCPCS code for the service furnished, a mental health revenue code, and for FQHCs, an appropriate FQHC mental health payment code. For detailed information on reporting mental health services and claims processing, see Pub. 100-04, Medicare Claims Processing Manual, chapter 9, http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c09.pdf

SOURCE: CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update, Jan. 26, 2023, pg. 38 (Accessed Jul. 2024).

RHCs and FQHCs may bill the Telehealth originating site facility fee on a RHC or FQHC claim under revenue code 0780 and HCPCS code Q3014. Telehealth services are the only services billed on FQHC claims that are subject to the Part B deductible. Additionally, a FQHC payment code and qualifying visit HCPCS code are not required when the only service reported on the claim is for Telehealth services. RHCs and FQHCs are not authorized to serve as distant practitioners for Telehealth services.

For more information on Telehealth services please see Pub 100-04, chapter 12, section 190: http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c12.pdf

SOURCE: CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Claims Processing Manual Ch. 9, Update, Jun 7, 2023, pg. 36 (Accessed Jul. 2024).

A face-to-face encounter means an in-person or telehealth encounter between the treating practitioner and the beneficiary.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 5: Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, 2/15/24, pg. 7, (Accessed Jul. 2024).

FQHCs/RHCs

RHCs and FQHCs are not authorized to serve as a distant site for telehealth consultations, which is the location of the practitioner at the time the telehealth service is furnished, and may not bill or include the cost of a visit on the cost report. This includes telehealth services that are furnished by an RHC or FQHC practitioner who is employed by or under contract with the RHC or FQHC, or a non-RHC or FQHC practitioner furnishing services through a direct or indirect contract. For more information on Medicare telehealth services, see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, and Pub. 100-04, Medicare Claims Processing Manual, chapter 12.

SOURCE: CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update, Jan. 26, 2023, pg. 41, (Accessed Jul. 2024).

Home Health (HH) Agencies

Starting on or after January 1, 2023, you may voluntarily report the use of telecommunications technology in providing HH services on HH payment claims. We’ll require this information on HH claims starting on July 1, 2023. You’ll submit the use of telecommunications technology on the HH claim using the following 3 G-codes:

G0320: Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system
G0321: Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system
G0322: The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (for example, remote patient monitoring)

SOURCE: Telehealth Home Health Services: G-Codes, MLN Matters MM12805, (Effective Date: Jan. 1, 2023), (Accessed Jul. 2024).

Can MFTs and MHCs perform telehealth services?

Yes. MFTs and MHCs have been added to the list of practitioners who can furnish Medicare telehealth services.

During the COVID-19 public health emergency (PHE), CMS used emergency waiver and other regulatory authorities so you could provide more services to your patients via telehealth. Section 4113 of the CAA, 2023 extended many of these flexibilities through December 31, 2024, and made some of them permanent. For more information refer to Telehealth Services Fact Sheet.

SOURCE: Centers for Medicare and Medicaid Services, Marriage and Family Therapists and Mental Health Counselors, Provider Enrollment Frequently Asked Questions, May 2024, (Accessed Jul. 2024).

Opioid Treatment Programs

During the Public Health Emergency (PHE) for the COVID-19 pandemic, as well as after the conclusion of the PHE, therapy and counseling may be furnished using audio-only telephone calls rather than via two-way interactive audio-video communication technology if two-way audio/video communications technology is not available to the beneficiary, provided all other applicable requirements are met, including circumstances in which the beneficiary is not capable of or does not consent to the use of devices that permit a two-way audio/video interaction

OTPs are allowed to furnish the substance use counseling, individual therapy, and group therapy included in the bundle via two-way interactive audio-video communication technology, as clinically appropriate, in order to increase access to care for beneficiaries. In addition, initiation of treatment with buprenorphine (but not methadone) via the OTP intake add-on code may be furnished via two-way audio-video communications technology to the extent that the use of audio-video telecommunications technology to initiate treatment with buprenorphine is authorized by DEA and SAMHSA at the time the service is furnished. For additional information please refer to Section 20 – Definitions relating to OTPs, C. Opioid use disorder treatment service. During the Public Health Emergency (PHE) for the COVID-19 pandemic, as well as after the conclusion of the PHE, therapy and counseling may be furnished using audio-only telephone calls rather than via two-way interactive audio-video communication technology if two-way audio/video communications technology is not available to the beneficiary, provided all other applicable requirements are met, including circumstances in which the beneficiary is not capable of or does not consent to the use of devices that permit a two-way audio/video interaction.

Beginning January 1, 2021, OTPs are allowed to use two-way interactive audio-video communication technology, as clinically appropriate, to furnish the periodic assessment add-on code. Additionally, during the PHE which expired on May 11, 2023, in cases where a beneficiary did not have access to two-way audio-video communications technology, periodic assessments could be furnished using audio-only telephone calls if all other applicable requirements were met. Through the end of CY 2024, in cases where a beneficiary does not have access to two-way audio-video communications technology, periodic assessments can be furnished using audio-only telephone calls if all other applicable requirements are met.

Beginning January 1, 2023, OTPs are allowed to furnish the OTP intake add-on code via two-way audio- video communication technology when billed for the initiation of treatment with buprenorphine, to the extent that the use of audio-video telecommunications technology to initiate treatment with buprenorphine is authorized by DEA and SAMHSA at the time the service is furnished. OTPs are also allowed to use audio- only communication technology to initiate treatment with buprenorphine in cases where audio-video technology is not available to the beneficiary, including circumstances in which the beneficiary is not capable of or has not consented to the use of devices that permit a two-way, audio/video interaction.

OTPs providing intensive outpatient services to Medicare beneficiaries with an OUD shall not receive payment under Medicare part B if the intensive outpatient services are furnished via audio-video or audio-only communications technology.

Telemedicine services should not, under any circumstances, expand the scope of practice of a healthcare professional or permit practice in a jurisdiction (the location of the patient) where the provider is not licensed.

Counseling or therapy furnished via communication technology as part of OUD treatment services furnished by an OTP must not be separately billed by the practitioner furnishing the counseling or therapy because these services would already be paid through the bundled payment made to the OTP.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 17: Opioid Treatment Programs (OTPs), 12/21/23, (Accessed Jul. 2024).

ELIGIBLE SITES

Temporary Policy – Ends Dec. 31, 2024

In the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, with respect to telehealth services identified in subparagraph (F)(i) as of March 15, 2022, that are furnished during the period beginning on the first day after the end of such emergency period and ending on December 31, 2024, the term “originating site” means any site in the United States at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system, including the home of an individual.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m) as amended by HR 2617 (2022 Session). (Accessed Jul. 2024).

Permanent Policy

Eligible Sites:

The office of a physician or practitioner.
A critical access hospital
A rural health clinic
A Federally qualified health center
A hospital
A hospital-based or critical access hospital- based renal dialysis center (including satellites).
A skilled nursing facility
Rural emergency hospital
A community mental health center
A renal dialysis facility for purposes of individuals with end-stage renal disease getting home dialysis.
The home of an individual, but only for purposes of individuals with end-stage renal disease getting home dialysis or telehealth services to treat substance use disorder or individuals with co-occurring mental health disorders, or mental health disorders under certain circumstances.
Mobile Stroke Unit
The home of an individual (only for purposes of treatment of a substance use disorder or a co-occurring mental health disorder, furnished on or after July 1, 2019, to an individual with a substance use disorder diagnosis.
The home of a beneficiary for the purposes of diagnosis, evaluation, and/or treatment of a mental health disorder for services that are furnished during the period beginning on the first day after the end of the emergency period as defined in our regulation at § 400.200 and ending on December 31, 2024 except as otherwise provided in this paragraph. Payment will not be made for a telehealth service furnished under this paragraph unless the following conditions are met:
- The physician or practitioner has furnished an item or service in-person, without the use of telehealth, for which Medicare payment was made (or would have been made if the patient were entitled to, or enrolled for, Medicare benefits at the time the item or service is furnished) within 6 months prior to the initial telehealth service;
- The physician or practitioner has furnished an item or service in-person, without the use of telehealth, at least once within 12 months of each subsequent telehealth service described in this paragraph, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens associated with an in-person service outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reason(s) for this decision in the patient’s medical record.
- The requirements of paragraphs (b)(3)(xiv)(A) and (B) may be met by another physician or practitioner of the same specialty and subspecialty in the same group as the physician or practitioner who furnishes the telehealth service, if the physician or practitioner who furnishes the telehealth service described under this paragraph is not available.

Note:

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act removed originating site geographic conditions and added an individual’s home as a permissible originating telehealth services substance use disorder or co-occurring mental health treatment site.
Medicare doesn’t apply originating site geographic conditions to hospital-based and CAH based renal dialysis centers, renal dialysis facilities, and patient homes when practitioners provide monthly ESRD-related medical evaluations in patient homes. Independent Renal Dialysis Facilities aren’t eligible originating sites.

SOURCE: Social Security Act, Sec. 1834(m) (US Code Title 42, Sec. 1395m) & 42 CFR Sec. 410.78. (Accessed Jul. 2024).

Requirements for mental health services furnished through telehealth (Delay of In-Person mental health requirement)

within the 6-month period prior to the first time such physician or practitioner furnishes such a telehealth service to the eligible telehealth individual; and
during subsequent periods in which such physician or practitioner furnishes such telehealth services to the eligible telehealth individual, at such times as the Secretary determines appropriate.

These requirements do not apply to services:

Under this paragraph (with respect to telehealth services furnished to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder); or
under this subsection without application of this paragraph.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

An originating site is the location where a patient gets physician or practitioner medical services through telehealth. Before the COVID-19 PHE, patients needed to get telehealth at an originating site located in a certain geographic location.

Through December 31, 2024, all patients can get telehealth wherever they’re located. They don’t need to be at an originating site, and there aren’t any geographic restrictions.

After December 31, 2024:

For non-behavioral or mental telehealth, there may be originating site requirements and geographic location restrictions
For behavioral or mental telehealth, all patients can continue to get telehealth wherever they’re located, with no originating site requirements or geographic location restrictions

Institutional Billing

Professional billing

Starting January 1, 2024, use:

POS 02: Telehealth Provided Other than in Patient’s Home
- Descriptor: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
POS 10: Telehealth Provided in Patient’s Home
- Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.
- Starting January 1, 2024, we pay for telehealth services you provide to patients in their homes at the non-facility PFS rate. See MLN Matters Article MM13452.

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Apr. 2024, (Accessed Jul. 2024).

Effective for claims with dates of service on and after January 1, 2024, claims for covered Telehealth services furnished at the distant site can be billed with POS code 10 when the patient is located in their home. Claims for covered Telehealth services using POS 10, if payable by Medicare, shall be paid at the Medicare Physician Fee Schedule non-facility rate.

The POS code 10 for Telehealth would not apply to originating site facilities billing a facility fee.

SOURCE: Centers for Medicare and Medicaid Services, Pub. 100-04, Medicare Claims Processing, Transmittal 12671, June 6, 2024, (Accessed Jul. 2024).

Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in either a rural health professional shortage area (HPSA) as defined by §332(a)(1) (A) of the Public Health Services Act or in a county outside of an MSA as defined by §1886(d)(2)(D) (go to the link and select the applicable title) of the Act.

Effective January 1, 2014, rural HPSAs include HPSAs located outside of a county outside of an MSA as well as those located in rural census tracts as determined by the Office of Rural Health Policy. Also effective January 1, 2014, geographic eligibility for an originating site is established for each calendar year based upon the status of the area as of December 31st of the prior calendar year.

Exception to rural HPSA and non MSA geographic requirements Entities participating in a Federal telemedicine demonstration project that were approved by or were receiving funding from the Secretary of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location. Such entities are not required to be in a rural HPSA or nonMSA.

The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. Originating sites authorized by law are listed below:

The office of a physician or practitioner;
A hospital (inpatient or outpatient);
A critical access hospital (CAH);
A rural health clinic (RHC);
A federally qualified health center (FQHC);
A hospital-based or critical access hospital-based renal dialysis center (including satellites) (effective January 1, 2009);
A skilled nursing facility (SNF) (effective January 1, 2009); and
A community mental health center (CMHC) (effective January 1, 2009).

NOTE: Independent renal dialysis facilities are not eligible originating sites.

Payment for Telehealth for Individuals with Acute Stroke

Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X); or

Telehealth originating site facility fee, billed with HCPCS code Q3014

The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, (Accessed Jul. 2024).

The list of settings where a physician’s services are paid at the facility rate include: …

Telehealth Provided Other than in Patient’s Home (POS code 02); …

Physicians’ services are paid at nonfacility rates for procedures furnished in the following settings:

Telehealth Provided in Patient’s Home (POS code 10);

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 12-13, (Accessed Jul. 2024).

SOURCE: Centers for Medicare and Medicaid Services, Medicare Learning Network Booklet 1986542, Medicare & Mental Health Coverage, Jan. 2024, (Accessed Jul. 2024).

CMS has directed place of service (POS) code 02 to be used for telehealth provided in places other than the patient’s home. POS code 10 should be used when telehealth is provided in the patient’s home.

SOURCE: Medicare Learning Network, MLN # MM12427, New/Modifications to the Place of Service POS Codes for Telehealth, Jan. 1, 2022 (implementation Apr. 4, 2022), (Accessed Jul. 2024).

In addition to the requirement for the in-person visit mentioned above in statute, CMS will also require there to be a an in-person, non-telehealth service within 12 months of each mental health telehealth service. However, if the patient and practitioner agree that the benefits of an in-person, non-telehealth service within 12 months of the mental health telehealth service are outweighed by risks and burdens associated with an in-person service, and the basis for that decision is documented in the patient’s medical record, the in-person visit requirement will not apply for that particular 12-month period. This applies only to patients receiving services at home. CMS will allow a clinician’s colleague in the same subspecialty in the same group to furnish the in-person, non-telehealth service to the beneficiary if the original practitioner is unavailable.

The home (for purposes of mental health reimbursement), can include temporary lodging, such as hotels and homeless shelters. CMS clarifies that for circumstances where the patient, for privacy or other personal reasons, chooses to travel a short distance from the exact home location during a telehealth services, the services is still considered to be furnished “in the home of an individual”.

In person requirement delayed under Medicare until on or after January 1, 2025.

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 63 & 64, & delay in implementation in HR 2617 (2022 Session). (Accessed Jul. 2024).

Treatment of stroke telehealth services

The requirements described in paragraph (4)(C) shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke, as determined by the Secretary.

With respect to telehealth services described in subparagraph (A), the term “originating site” shall include any hospital (as defined in section 1861(e)) or critical access hospital (as defined in section 1861(mm)(1)), any mobile stroke unit (as defined by the Secretary), or any other site determined appropriate by the Secretary, at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

After consideration of public comments, we are finalizing as proposed that beginning in CY 2024, claims for telehealth services billed with POS 10 will be paid at the non-facility PFS rate. Claims billed with POS 02 will continue to be paid at the facility rate. In addition, we are clarifying that modifier ’95’ should be used when the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services furnished via telehealth by PT, OT, or SLP.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Jul. 2024).

Accountable Care Organizations (two-sided model tested or expanded under 1115A of the Social Security Act)

In the case of telehealth services described in paragraph (1) where the home of a Medicare fee-for-service beneficiary is the originating site, the following shall apply:

There shall be no facility fee paid to the originating site under section 1834(m)(2)(B).
No payment may be made for such services that are inappropriate to furnish in the home setting such as services that are typically furnished in inpatient settings such as a hospital.

SOURCE: Social Security Act Sec. 1899 (Accessed Jul. 2024).

Hospital Expansion Site

Hospitals Able to Provide Care in Temporary Expansion Sites: As part of the CMS Hospital Without Walls initiative during the PHE, hospitals could provide hospital services in other hospitals and sites that otherwise would not have been considered part of a healthcare facility, or could set up temporary expansion sites to help address the urgent need to increase capacity to care for patients. During the PHE, CMS provided additional flexibilities for hospitals to create surge capacity by allowing them to provide room and board, nursing, and other hospital services at remote locations, such as hotels or community facilities. During the PHE, hospitals are expected to control and oversee the services provided at an alternative location. When the PHE ends, hospitals and CAHs will be required to provide services to patients within their hospital departments, pursuant to Hospital and CAH conditions of participation at 42 CFR part 482 and part 485, Subpart F, respectively.

Hospital Without Walls

CMS permitted ambulatory surgical centers (ASCs) to temporarily reenroll as hospitals and to provide hospital services to help address the urgent need to increase hospital capacity to take care of patients. Other interested entities, such as independent, freestanding, emergency departments (IFEDs), could pursue temporarily enrolling as a hospital during the PHE. (As of December 1, 2021, no new ASC or new IFED requests to temporarily enroll as hospitals were being accepted.) See https://www.cms.gov/files/document/provider-enrollment-relief-faqscovid-19.pdf for additional information. When the PHE ends, ASCs must decide either to meet the certification standards for hospitals at 42 CFR part 482, or return to ASC status. If they choose to return to ASC status, they can only be paid under the ASC payment system for services on the ASC Covered Procedures List. When the PHE ends, IFEDs cannot bill Medicare for services as their temporary Medicare certification would end.

SOURCE: Centers for Medicare and Medicaid Services, Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs: CMS Flexibilities to Fight COVID-19, 6/26/23, (Accessed Jul. 2024).

If the Hospitals Without Walls Initiative expires at the end of the day on May 11, 2023, why are beneficiaries able to receive mental/behavioral health services in their home from hospital staff through the use of telecommunications technology after that date?

The flexibilities currently in place under the Hospital Without Walls Initiative during the COVID-19 PHE allowed hospitals to bill for services furnished by hospital clinical staff to beneficiaries in their homes using telecommunications technology, because the home was considered a provider-based department of the hospital. The services included a subset of hospital outpatient therapy, counseling, and educational services, beyond just mental/behavioral health services.

After the PHE ends, in some circumstances, hospitals will continue to be able to bill for mental/behavioral health services furnished to beneficiaries in their homes by hospital staff using telecommunications technology permanently. This policy only applies when no separate professional service is billable, as finalized in the calendar year 2023 Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems final rule (87 FR 71748). These services are considered “remote mental health services.” However, once the beneficiary’s home is no longer considered a provider-based department of the hospital after the end of the PHE, the hospital staff will no longer be able to bill for other outpatient services furnished to beneficiaries in the home.

Notably, in accordance with the Consolidated Appropriations Act, 2023, eligible distant site physicians and practitioners may still be able to bill as a Medicare telehealth service under the Medicare physician fee schedule for professional services furnished via telehealth to individuals in their homes through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Jul. 2024).

When physical and occupational therapists were allowed to provide services via telehealth, CMS used waiver authority to implement the Hospital Without Walls (HWW) policy that allowed the patients’ home to be classified as part of the hospital. This allowed the hospital “to bill both the hospital facility payment in association with professional services billed under the PFS and single payment for a limited number of practitioners services, when statute or other applicable rules only allow the hospital to bill for services personally provided by their staff. These services are either billed by hospitals or by professionals, there would not be separate facility and professional billing.” When the PHE ended, CMS originally thought to end this policy but is now considering whether some institutions may be able to bill for certain services provided remotely by employed practitioners. Therefore, institutional staff providing outpatient therapy, DSMT and MNT services via telehealth may bill the same way they did during the PHE until the end of 2024. For hospitals, beneficiaries’ homes will no longer need to be registered as provider-based departments of the hospital to allow for hospitals to bill for these services. With the exception of Method II critical access hospitals (CAHs), the 95 modifier will be used on each applicable line if telehealth is used. CAHs using Method II payment will continue using GT/GQ.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Jul. 2024).

02 Telehealth Provided Other than in Patient’s Home (January 1, 2017): The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
10 Telehealth Provided in Patient’s Home (January 1, 2022): The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

Beginning in CY 2024, practitioners may receive either the facility or the non-facility payment rate for an otherwise eligible Medicare telehealth service, depending on whether the billing practitioner selects POS code 02 or POS code 10. The only two valid POS codes for Medicare telehealth billing in CY 2024 are POS 02 and POS 10. As appropriate, POS 02 or POS 10 may be used and must be paired with the appropriate telehealth modifier (modifier 93 for audio-only and modifier 95 for audio/video). The payment rate for POS 02 is the facility payment rate (F); the payment rate for POS 10 is the non-facility rate (NF). Use of audio-only (93) or audio-video (95) does not change rate of payment, only the POS code determines the non-facility or facility payment rate.

Mobile Unit Setting

A physician or practitioner’s office, even if mobile, qualifies to serve as a telehealth originating site. Assuming such an office also fulfills the requirement that it be located in either a rural health professional shortage area as defined under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A)) or in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act, the originating physician’s office should use POS code 11 (Office) in order to ensure appropriate payment for services on the list of Medicare Telehealth Services.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 26: Completing and Processing Form CMS-1500 Data Set, 6/6/24, pg. 23-32, (Accessed Jul. 2024).

Home Health Services

The face-to-face encounter can be performed via a telehealth service, in an approved originating site. An originating site is considered to be the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a rural health professional shortage area or in a county outside of a Metropolitan Statistical Area.

Entities that participate in a Federal telemedicine demonstration project approved by (or receiving funding from) the Secretary of the Department of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location.

The originating sites authorized by law are:

The office of a physician or practitioner;
Hospitals;
Critical Access Hospitals (CAH);
Rural Health Clinics (RHC);
Federally Qualified Health Centers (FQHC);
Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
Skilled Nursing Facilities (SNF); and
Community Mental Health Centers (CMHC).

Section 1895(e) governs the home health prospective payment system (PPS) and provides that telehealth services are outside the scope of the Medicare home health benefit and home health PPS.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 7: Home Health Services, 12/21/23, (Accessed Jul. 2024).

FQHCs/RHCs

RHCs and FQHCs may serve as an originating site for telehealth services, which is the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. RHCs and FQHCs that serve as an originating site for telehealth services are paid an originating site facility fee.

Although FQHC services are not subject to the Medicare deductible, the deductible must be applied when an FQHC bills for the telehealth originating site facility fee, since this is not considered an FQHC service.

SOURCE: CMS, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update, Jan. 26, 2023, pg. 41, (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

Temporary Policy – Ends Dec. 31, 2024

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

Permanent Policy

The term “originating site” means only those sites described below:

In an area that is designated as a rural health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act
In a county that is not included in a Metropolitan Statistical Area; or
From an entity that participates in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary of Health and Human Services as of December 31, 2000.

The geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of the home dialysis monthly ESRD-related visit, at a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home.

Additional exceptions exist for treatment of acute stroke, substance use disorder and mental health (see below).

The Health Resources and Services Administration (HRSA) decides HPSAs and the Census Bureau decides MSAs. Find potential Medicare telehealth originating site payment eligibility at HRSA’s Medicare Telehealth Payment Eligibility Analyzer.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m), (Accessed Jul. 2024).

NOTE: Independent renal dialysis facilities are not eligible originating sites.

SOURCE: Center for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysicians Practitioners (Jun. 6, 2024), p. 145. (Accessed July. 2024).

Treatment of stroke telehealth services

The geographic requirements described in paragraph (4)(C)(i) shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of section 1881(b)(3)(B), at an originating site described in subclause (VI), (IX), or (X) of paragraph (4)(C)(ii).

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

Through December 31, 2024, all patients can get telehealth wherever they’re located. They don’t need to be at an originating site, and there aren’t any geographic restrictions.

After December 31, 2024:

For non-behavioral or mental telehealth, there may be originating site requirements and geographic location restrictions
For behavioral or mental telehealth, all patients can continue to get telehealth wherever they’re located, with no originating site requirements or geographic location restrictions

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Apr. 2024, (Accessed Jul. 2024).

Except as provided in paragraph (b)(4)(iv) of this section, originating sites must be:

Located in a health professional shortage area (as defined under section 332(a)(1)(A) of the Public Health Service Act that is either outside of a Metropolitan Statistical Area (MSA) as of December 31st of the preceding calendar year or within a rural census tract of an MSA as determined by the Office of Rural Health Policy of the Health Resources and Services Administration as of December 31st of the preceding calendar year, or
Located in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act as of December 31st of the preceding year, or
An entity participating in a Federal telemedicine demonstration project that has been approved by, or receive funding from, the Secretary as of December 31, 2000, regardless of its geographic location.

The geographic requirements specified above do not apply to the following telehealth services:

Home dialysis monthly ESRD-related clinical assessment services furnished on or after January 1, 2019, at an originating site described in paragraphs (b)(3)(vi), (ix) or (x) of this section, in accordance with section 1881(b)(3)(B) of the Act; and
Services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
Services furnished on or after July 1, 2019 to an individual with a substance use disorder diagnosis, for purposes of treatment of a substance use disorder or a co-occurring mental health disorder.
Services furnished on or after January 1, 2025 for the purposes of diagnosis, evaluation, and/or treatment of a mental health disorder. Payment will not be made for a telehealth service furnished under this paragraph unless the physician or practitioner has furnished an item or service in person, without the use of telehealth, for which Medicare payment was made (or would have been made if the patient were entitled to, or enrolled for, Medicare benefits at the time the item or service is furnished) within 6 months prior to the initial telehealth service and within 6 months of any subsequent telehealth service.

SOURCE: 42 CFR Sec. 410.78 (Accessed Jul. 2024).

Accountable Care Organizations (two-sided model tested or expanded under 1115A of the Social Security Act)

In the case of telehealth services for which payment would otherwise be made under this title furnished on or after January 1, 2020, the geographic limitation shall not apply with respect to any eligible originating site (including the home of a beneficiary) subject to State licensing requirements.

SOURCE: Social Security Act Sec. 1899 (Accessed Jul. 2024).

Payment for Telehealth for Individuals with Acute Stroke

Effective for claims with dates of service on and after January 1, 2019, contractors shall accept new informat HCPCS modifier G0 (G zero), to be used to identify Telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke. Modifier G0 is valid for all:

Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X); or
Telehealth originating site facility fee, billed with HCPCS code Q3014

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, (Accessed Jul. 2024).

Home Health Services

The originating sites authorized by law are:

The office of a physician or practitioner;
Hospitals;
Critical Access Hospitals (CAH);
Rural Health Clinics (RHC);
Federally Qualified Health Centers (FQHC);
Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
Skilled Nursing Facilities (SNF); and
Community Mental Health Centers (CMHC).

Section 1895(e) governs the home health prospective payment system (PPS) and provides that telehealth services are outside the scope of the Medicare home health benefit and home health PPS.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch. 7: Home Health Services, 12/21/23, (Accessed Jul. 2024).

FACILITY/TRANSMISSION FEE

Eligible originating sites are eligible for a facility fee equal to:

for the period beginning on October 1, 2001, and ending on December 31, 2001, and for 2002, $20; and
for a subsequent year, the facility fee specified in subclause (I) or this subclause for the preceding year increased by the percentage increase in the MEI (as defined in section 1842(i)(3)) for such subsequent year.

No facility fee shall be paid under this subparagraph to an originating site that is the home.

Treatment of Acute Stroke: No facility fee shall be paid to an originating site with respect to a telehealth service if the originating site does not otherwise meet the requirements for an originating site, including geographic requirements.

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

No facility fee for new sites. In the case that the emergency period described in section 1320b–5(g)(1)(B) of this title ends before December 31, 2024, with respect to telehealth services identified in paragraph (4)(F)(i) as of March 15, 2022, that are furnished during the period beginning on the first day after the end of such emergency period and ending December 31, 2024, a facility fee shall only be paid under this subparagraph to an originating site that is described in paragraph (4)(C)(ii) (other than subclause (X) of such paragraph).

SOURCE: Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m). (Accessed Jul. 2024).

The originating site facility fee is a separately billable Part B payment. The contractor pays it outside of other payment methodologies. This fee is subject to post payment verification.

For telehealth services furnished from October 1, 2001, through December 31, 2002, the originating site facility fee was the lesser of $20 or the actual charge. For services furnished on or after January 1 of each subsequent year, the originating site facility fee is updated by the Medicare Economic Index. The updated fee is included in the Medicare Physician Fee Schedule (MPFS) Final Rule, which is published by November 1 prior to the start of the calendar year for which it is effective. The updated fee for each calendar year is also issued annually in a Recurring Update Notification instruction for January of each year. See manual for more information about the payment amount and billing procedures for different types of entities.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 12 – Physicians/Nonphysician Practitioners, Revised 6/6/24, pg. 145, (Accessed Jul. 2024).

Hospital Originating Site Facility Fee for Professional Services Furnished Via Telehealth: When a physician or nonphysician practitioner, who typically furnishes professional services in the hospital outpatient department, furnishes telehealth services to the patient’s home during the COVID-19 PHE as a “distant site” practitioner, they bill with a hospital outpatient place of service, since that is likely where the services would have been furnished if not for the COVID19 PHE. The physician or practitioner is paid for the service under the PFS at the facility rate, which does not include payment for resources, such as clinical staff, supplies, or office overhead, since those things are usually supplied by the hospital outpatient department. The hospital may bill under the OPPS for the originating site facility fee associated with the telehealth service.

SOURCE: Centers for Medicare and Medicaid Services, Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs: CMS Flexibilities to Fight COVID-19, 6/26/23, (Accessed Jul. 2024).

After the end of the PHE, can hospitals bill for the originating site facility fee (HCPCS code Q3014) when a beneficiary is not in the hospital but a hospital-based outpatient department physician furnishes a Medicare telehealth service and the hospital provides administrative and clinical support?

No. Following the anticipated end of the PHE (May 11, 2023), hospitals will no longer be able to bill HCPCS code Q3014 to account for the resources associated with administrative support for a professional Medicare telehealth service.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Jul. 2024).

HCPCS Code Q3014 describes the Medicare telehealth originating sites facility fee. Bill your MAC for the separately billable Part B originating site facility fee. The payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80% of the lesser of the actual charge ($28.64 for CY 2023 services and $29.96 for CY 2024 services). We base this on the percentage increase in the Medicare Economic Index (MEI) as defined in section 1842(i)(3) of the Social Security Act. The 2023 MEI increase is 3.8%. The patient is responsible for any unmet deductible amount and coinsurance. See MLN Matters Article MM12982 to learn about the CY 2023 Medicare Physician Fee Schedule Final Rule Summary.

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Apr. 2024, (Accessed Jul. 2024).

Indian Health Services

All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (all-inclusive ancillary) on TOB 12X (hospital inpatient Part B). Medicare Part B deductible and coinsurance amounts are applied to inpatient Medicare Part B ancillary services, but are waived by the IHS. The MSN is suppressed.

All charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).

Effective January 1, 2009, IHS providers, including CAHs are paid separately from the AIR for the Telehealth Originating Site Facility Fee. HCPCS code Q3014 (“telehealth originating site facility fee”) is a Part B benefit. The fee is updated each calendar year by the Medicare Economic Index announced in the annual Physician Fee Schedule Final Regulation.

IHS providers are paid for HCPCS code Q3014 at the fee schedule payment, not the provider’s usual all-inclusive payment methodology (e.g., inpatient DRG or AIR or CAH per diem). For CAHs, the payment amount is 80 percent of the fee, not 101 percent of cost.

The Medicare Part B deductible and coinsurance apply to the Telehealth Originating Site Facility Fee, but are waived by the IHS.

The Telehealth Originating Site Facility Fee is reported on TOB 12X, 13X or 85X along with the revenue code 0780 and HCPCS code Q3014 as described in Chapter 12, Section 190 of Pub. 100-04, Medicare Claims Processing Manual.

No clinic visit shall be billed if this is the only service received. There is no requirement that a practitioner present the patient for interactive telehealth services.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 19: Indian Health Services, 5/20/22, pg. 36, 51-52, (Accessed Jul. 2024).

Federally Qualified Health Centers/Rural Health Clinics

SOURCE: Center for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 9 – Rural Health Clinics/Federally Qualified Health Centers (Jun. 7, 2023), p. 36. (Accessed Jul. 2024).

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Alabama

Last updated 06/18/2024

POLICY

This general information is related to the telehealth medical …

POLICY

This general information is related to the telehealth medical services rendered by Alabama Medicaid (Medicaid) providers. Providers are expected to comply with Alabama’s Telehealth Medical Services law (Code of Alabama, Sections 34-24-701 through 34-24-707) at all times.

Services must be administered via an interactive audio or audio and video telecommunications system which permits two-way communication between the distant site provider and the site where the recipient is located (this does not include electronic mail message or facsimile transmission between the provider and recipient).

Providers meeting the telemedicine provider requirements listed above must append one of the following modifiers indicating the mode of telemedicine service delivery:

GT for covered telemedicine services delivered via audio and visual telecommunications.
FQ for covered telemedicine services delivered via audio only telecommunications.

Additional modifiers may be required. Refer to the chapter of the Provider Billing Manual that describes services provided for further information.

Reimbursement for services provided via telemedicine, audio only and audio and video telecommunications, will be paid at parity to those services provided face-to-face. Medicaid will continue to monitor and reevaluate, if deemed necessary.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jul. 2024, (Accessed Jun. 2024).

Telemedicine: Telemedicine services are covered for limited specialties and under special circumstances. Refer to the Alabama Medicaid Provider Manual, Chapter 28 for details on coverage.

SOURCE: AL Admin. Code r. 560-X-6-.14(f)(5). (Accessed Jun. 2024).

Therapy Services

Services must be administered via an interactive audio and video telecommunications system which permits two-way communication between the distant site provider and the origination site where the recipient is located (this does not include a telephone conversation, electronic mail message, or facsimile transmission between the provider, recipient, or a consultation between two providers).

Telemedicine health care providers shall ensure that the telecommunication technology and equipment used at the recipient site and at the provider site, is sufficient to allow the provider to appropriately evaluate, diagnose, and/or treat the recipient for services billed to Medicaid. Transmissions must utilize an acceptable method of encryption adequate to protect the confidentiality and integrity of the transmission information. Transmissions must employ acceptable authentication and identification procedures by both the sender and the receiver.

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Jul. 2024, pg. 17, (Accessed Jun. 2024).

Several manual chapters refer to telemedicine chapter for information.

ELIGIBLE SERVICES/SPECIALTIES

Services rendered via telecommunication system must be provided by a provider who is licensed, registered, or otherwise authorized to engage in his or her healthcare profession in the state where the patient is located. Per Alabama law, the provision of telemedicine medical services is deemed to occur at the patient’s originating site within this state.

Services must be within the provider’s scope of license.

Services must be provided to a recipient that is an established patient of the provider or practice or due to a referral made by a patient’s licensed physician with whom the patient has an established physician-patient relationship, in the usual course of treatment of the patient’s existing health condition.

A covered telemedicine service will count towards each recipient’s benefit limit of 14 annual physician office visits.

Specific covered services list provided in manual by provider type (page. 8-10).

Services NOT Eligible for Reimbursement for Telemedicine Services

Common examples of services via telemedicine not considered for reimbursement (not exhaustive):

Chart reviews
Electronic mail messages (between providers and recipients)
Facsimile transmissions (between providers and recipients)
Consultation between two providers
Internet based communications that are not HIPAA-compliant or secure
Services not directly provided by an enrolled provider or by office staff
Services not normally charged for during an office visit
Services not specifically listed in Provider Billing Manual chapters
Communication that is not secure or HIPAA-compliant (e.g., Skype, FaceTime)

Exceptions may be made to the lists for providers and services not reimbursable under this policy in the event of a public health emergency, however, separate guidance would be issued in those instances.

BMI Requirements

The BMI will be required for office visits including the telemedicine visits. The BMI is required at least once per calendar year on all claims with procedure codes 99201-99205, 99211- 99215, and 99241-99245 and EPSDT procedure codes 99382-99385 and 99392-99395. Providers should use subjective data to calculate the BMI which can include providers asking the recipient for his or her height and weight during the telemedicine visit. The BMI should be calculated, based on the information provided by the recipient, and appended to the claim for reimbursement. The BMI should also be documented in the recipient’s medical record.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jul. 2024 (Accessed Jun. 2024).

Telemedicine services are covered for limited specialties and under special circumstances.

SOURCE: AL Admin. Code r. 560-X-6-.14(f)(5). (Accessed Jun. 2024).

Rehabilitation services that are delivered face to face can either be in person or via telemedicine/telehealth, as approved by the Alabama Medicaid Agency. Some services in manual specify that they can be delivered in person or via telemedicine.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services – DMH, DHR, DYS, DCA, Ch. 105, Jul. 2024. (Accessed Jun. 2024).

ABA Therapy Services

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Jul. 2024, pg. 17, (Accessed Jun. 2024).

Nurse-Family Partnership

NFP nurse visiting services include care coordination, assessments and screenings, case management, and preventative health education and counseling. These nursing services are tailored to each woman’s needs and delivered in-person or via telehealth in the home setting, or in an alternative community setting as indicated by recipient’s need.

Effective January 1, 2024, at least one of the minimal two monthly visits must be in-person or face-to-face to be eligible for reimbursement by Medicaid.

SOURCE: AL Medicaid Management Information System Provider Manual, Nurse Family Partnership, Ch. 41, Jul. 2024, (Accessed Jun. 2024).

Prescriptions for Certain Home Health Services

The required face-to-face visit may be conducted using telehealth systems.

SOURCE: AL Admin Code 560-X-6-.01, (Accessed Jun. 2024).

Behavioral Health

Refer to Chapter 112, Telemedicine Services, for general information and limitations.

SOURCE: AL Medicaid Management Information System Provider Manual, Behavioral Health, Ch. 34, Jul. 2024, (Accessed Jun. 2024).

A Well Child Check Up

Refer to Chapter 112, Telemedicine Services, for general benefit information and limitations.

SOURCE: AL Medicaid Management Information System Provider Manual, A Well Child Check-Up (EPSDT), A-5, Jul. 2024, (Accessed Jun. 2024).

Targeted Case Management

Refer to Chapter 112, Telemedicine Services, for general information and limitations.

SOURCE: AL Medicaid Management Information System Provider Manual, Targeted Case Management, Ch. 106-27, Jul. 2024, (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

Providers must submit the Telemedicine Service Agreement/Certification to Medicaid’s fiscal agent. The form is located on the Medicaid website at: www.medicaid.alabama.gov. Once the form is received, providers will be enrolled with Medicaid with a specialty type of 931 (Telemedicine Service). Providers must have the specialty type of 931 to bill for telemedicine services.

Provider Types Eligible for Reimbursement for Telemedicine Services

Physicians
Certified Registered Nurse Practitioners (CRNPs)
Physician Assistants
Rehabilitative Option Providers
Psychologists
Licensed Professional Counselors
Associate Licensed Counselors
Licensed Marriage and Family Therapist and Associates
Licensed Master Social Workers
Licensed Independent Clinical Social Workers
Licensed Psychological Technicians
Speech Therapists
Optometrists
Applied Behavior Analysts
Early Intervention
Children’s Rehabilitation Service
Pharmacists/Pharmacies
Targeted Case Management

Provider Types NOT Eligible for Telemedicine Reimbursement

Physical Therapists
Occupational Therapists
DME suppliers
Ambulance providers
Chiropractors
Home Infusion
Laboratory

Refer to the respective Alabama Medicaid Provider Billing Manual chapter that describes the service rendered by providers listed above for general enrollment information.

Telemedicine Provider Requirements

Providers must identify themselves to the recipient with their credentials and name at the time of service.

Providers must obtain prior written or verbal consent from the recipient before services are rendered.

Telemedicine services may only be provided as a result of a patient’s request, part of an expected follow up, or a referral from the patient’s licensed physician with whom the patient has an established patient-physician relationship.

Services must be within the provider’s scope of license.

Telemedicine services provided to minors under the age of medical consent must have a parent or legal guardian attend the telemedicine visit.

Only the provider rendering the services via telemedicine may submit for reimbursement for services.

Providers must indicate an in-state or qualifying bordering state site of practice address from which telemedicine services will be provided.

Note: This policy does not expand or grant any authority outside that authority granted to the provider by their respective licensure board or by federal or state law.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jul. 2024, (Accessed Jun. 2024).

Telemedicine providers who render maternity related services are required to sign a DHCP agreement with one of the ACHNs to receive reimbursement from Medicaid. Refer to Chapter 112 of the Provider Billing Manual to determine further requirements and procedure codes for telemedicine services.

Beginning July 8, 2020, Medicaid will allow physicians enrolled with the specialties OB/GYN (specialty type 328) and telemedicine (specialty type 931) to be reimbursed for maternity services with a referral from either an ACHN or the referring DHCP. The NPI of the ACHN, the DHCP, or the referring DHCP’s group must be on the claim for reimbursement. Refer to section 40.43.2 (DHCP Selection Referral Number) for more detailed billing information.

Telemedicine providers who render maternity-related services are required to sign a Non-Delivering Telemedicine DHCP Participation agreement with at least one of the ACHNs in order to receive reimbursement from Medicaid. Refer to Chapter 112 of the Provider Billing Manual to determine further requirements and procedure codes allowed for telemedicine services.

SOURCE: AL Medicaid Management Information System Provider Manual, Alabama Coordinated Health Network (ACHN) Primary Care Physician (PCP) and Delivering Healthcare Professional (DHCP) Billing, (Manual Ch. 40-p. 33). Jul. 2024, (Accessed Jun. 2024).

Rehabilitation services that are delivered face to face can either be in person or via telemedicine/telehealth, as approved by the Alabama Medicaid Agency.

All services rendered by a physician, physician assistant, or nurse practitioner that meet the definition above should be billed under this code including those rendered via teleconference with a direct service or consultation recipient. Please refer to the section titled Telehealth Billing Guidelines for more information.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services – DMH, DHR, DYS, DCA, Sec. 105, Jul. 2024. (Accessed Jun. 2024).

The face-to-face encounter required for the ordering of home health services may be conducted using telehealth systems.

SOURCE: AL Medicaid Management Information System Provider Manual, Home Health (17-p. 2) Jul. 2024, (Accessed Jun. 2024).

The required face-to-face visit may be conducted using telehealth systems.

SOURCE: AL Medicaid Management Information System Provider Manual, Durable Medical Equipment, 14-10, Jul. 2024. (Accessed Jun. 2024).

Therapy Services

The provider shall maintain appropriately trained staff, or employees, familiar with the recipient’s treatment plan, immediately available in-person to the recipient receiving a telemedicine service to attend to any urgencies or emergencies that may occur during the session. The provider shall implement confidentiality protocols that include, but are not limited to:

specifying the individuals who have access to electronic records; and
usage of unique passwords or identifiers for each employee or other person with access to the client records; and
ensuring a system to prevent unauthorized access, particularly via the Internet; and
ensuring a system to routinely track and permanently record access to such electronic medical information

These protocols and guidelines must be available to inspection at the telemedicine site and to the Medicaid Agency upon request.

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Jul. 2024, pg. 17, (Accessed Jun. 2024).

For ABA therapy or PBS services listed above provided via telemedicine, enrolled providers are eligible to participate in the Telemedicine Program to provide medically necessary telemedicine services to Alabama Medicaid eligible recipients. In order to participate in the telemedicine program:

Providers must be enrolled with Alabama Medicaid with a specialty type of 931 (Telemedicine Service).
To be enrolled with the 931 specialty, providers must submit the Telemedicine Service Agreement/Certification form which is located on the Medicaid website at: www.medicaid.alabama.gov. Electronic signatures will be acceptable for the telemedicine agreement. The agreement may be uploaded through the provider web portal along with a request to add the 931 specialty. See Chapter 2 – Becoming a Medicaid Provider for further information.
Providers must obtain prior consent from the recipient before services are rendered. A sample recipient consent form is attached to the Telemedicine Service Agreement.

SOURCE: AL Medicaid Management Information System Provider Manual, Therapy Services, Jul. 2024, pg. 16-17, (Accessed Jun. 2024).

Provider-Based RHCs and RHCs Independent

When not physically present, the physician must be available at all times through direct telecommunication for consultation, assistance with medical emergencies or patient referral.

SOURCE: AL Medicaid Management Information System Provider Manual, Provider-Based RHCs, Jul. 2024, Ch. 32, pg. 2, & AL Medicaid Management Information System Provider Manual, RHCs Independent, Jul. 2024, Ch. 36, pg. 3, (Accessed Jun. 2024).

Certified Registered Nurse Practitioner and Physician Assistant

CRNPs are assigned a provider type of 09 (Nurse Practitioner). Valid specialties for CRNPs include the following: …

Telemedicine Service (931)

SOURCE: AL Medicaid Management Information System Provider Manual, Certified Registered Nurse Practitioner and Physician Assistant, Ch. 21 Jul. 2024, pg. 2, (Accessed Jun. 2024).

Eye Care Services

Opticians are assigned a provider type of 19. Optometrists are assigned a provider type of 18. Valid specialties for Eye Care providers include the following: …

Telemedicine (931) Ophthalmologist and Optometrist

SOURCE: AL Medicaid Management Information System Provider Manual, Eye Care Services, Ch. 15, Jul. 2024, pg. 2, (Accessed Jun. 2024).

ELIGIBLE SITES

The following are required for the origination site where the patient is located:

The site provider shall ensure that the telecommunication technology and equipment used at the origination site is HIPAA compliant and is sufficient to allow the appropriate evaluation, diagnosis, and/or treatment of the patient.
The site provider shall implement protocols that ensure the same confidentiality of the telemedicine visit as for in-person visits.
Regardless of the location of the recipient, it is the provider’s responsibility to ensure the telemedicine visit meets all required HIPAA rules and regulations regarding telemedicine visits.

The following sites are recognized by Medicaid as origination sites:

Physician and practitioner offices
Hospitals
Rural Health Clinics (RHCs)
Federally Qualified Health Centers (FQHCs)
Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
Skilled Nursing Facilities (SNFs)
Community Mental Health Centers (CMHCs)
Renal Dialysis Facilities
Mobile Stroke Units
Alabama Department of Public Health

Telemedicine services can be rendered to a recipient in their home. However, a recipient’s home should not be considered an origination site entitled to receive an origination site fee.

Note: If a Medicaid-enrolled provider performs another medically necessary service(s), the provider may bill for the covered service(s) in addition to providing his/her facility as an origination site and be eligible for reimbursement for the origination site facility fee and the other medically necessary service(s).

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jul. 2024, pg. 5, (Accessed Jun. 2024).

Certified Registered Nurse Practitioner and Physician Assistant

The following place of service codes apply when filing claims for CRNP services:

02 – Telemedicine Services

SOURCE: AL Medicaid Management Information System Provider Manual, Certified Registered Nurse Practitioner and Physician Assistant, Ch. 21 Jul. 2024, pg. 8, (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

No reference found.

FACILITY/TRANSMISSION FEE

Effective April 1, 2020, Medicaid pays an origination site facility fee of $20.00. The origination fee will be limited to one per date of service per recipient and may be billed by all of the providers listed above under Origination Sites.

No origination site facility fee will be paid for an origination site not listed above. See manual for billing instructions.

A recipient’s home should not be considered an origination site entitled to receive an origination site fee.

SOURCE: AL Medicaid Management Information System Provider Manual, Telemedicine Services, Ch. 112, Jul. 2024, (Accessed Jun. 2024).

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Alaska

Last updated 06/19/2024

POLICY

The department shall pay for all services covered by …

POLICY

The department shall pay for all services covered by the medical assistance program provided through telehealth if the same manner as if the services had been provided in person (see Eligible Services Section below for eligible services).

The department shall adopt regulations for services provided by telehealth, including setting rates of payment. Regulations calculating the rate of payment for a rural health clinic or federally qualified health center must treat services provided through telehealth in the same manner as if the services had been provided in person, including calculations based on the rural health clinic’s or federally qualified health center’s reasonable costs or on the number of visits for recipients provided services, and must define “visit” to include a visit provided by telehealth. The department may not decrease the rate of payment for a telehealth service based on the location of the person providing the service, the location of the eligible recipient of the service, the communication method used, or whether the service was provided asynchronously or synchronously. The department may exclude or limit coverage or reimbursement for a service provided by telehealth, or limit the telehealth modes that may be used for a particular service, only if the department

specifically excludes or limits the service from telehealth coverage or reimbursement by regulations adopted under this subsection;
determines, based on substantial medical evidence, that the service cannot be safely provided using telehealth or using the specified mode; or
determines that providing the service using the specified mode would violate federal law or render the service ineligible for federal financial participation under applicable federal law.

All services delivered through telehealth under this section must comply with the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191).

SOURCE: AK Statute Sec. 47.07.069, (Accessed Jun. 2024).

Subject to the requirements of 7 AAC 110.620 – 7 AAC 110.639, the department will pay for a service delivered by means of one of the following telehealth modalities if the modality and use of the modality meet the requirements of P.L. 104 – 191 (Health Insurance Portability and Accountability Act of 1996 (HIPAA)):

synchronous: live or interactive, through a real-time, interactive
- two-way audio-video technology that includes, at a minimum, an operational camera, microphone, speaker or headphones, and capability to view video feed;
- two-way audio-only technology that allows for oral communication between the provider and the recipient;

SOURCE: AK Admin. Code, Title 7, 110.625. (Accessed Jun. 2023).

Alaska Medicaid will pay for a covered medical service furnished through telemedicine application if the service is:

Covered under traditional, non-telemedicine methods;
Provided by a treating, consulting, presenting or referring provider;
Appropriate for provision via telemedicine

Note: Manual is under review.

Source: State of AK Dept. of Health and Social Svcs, Alaska Medical Assistance Provider Billing Manuals for Physician, PA, ARNP Services (5/13), p. 31, (Accessed Jun. 2024).

On July 13th, 2023, the Department of Health (DOH) adopted revised regulations for Medicaid coverage and payment for healthcare services provided through telehealth. These regulations went into effect September 1st, 2023. The department is in process of amending current telehealth guidance and updating system rules to accommodate these changes. This document is intended to answer common questions regarding Alaska Medicaid coverage and reimbursement of services provided through a telehealth modality as of September 1st, 2023.

What are the covered modalities for telehealth services?

Synchronous through a real-time, interactive:

Two-Way Audio-Video Technology: Includes, at minimum, an operational camera, microphone, speaker or headset, and capability to view video feed, or
Two-Way Audio Only Technology: Includes an operational microphone and speaker or headphones.

Asynchronous:

Store-and-Forward: The transfer between healthcare providers of recorded digital images, video, or sounds from one location to another.

Patient-Initiated Online Digital Services:

Synchronous or asynchronous: Evaluation, assessment, and management services of an established patient through a secure platform such as an electronic record portal, secure electronic mail, or digital application.

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023), (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Subject to the requirements of 7 AAC 110.620 – 7 AAC 110.639, the department will pay for a service delivered by means of a telehealth modality if the service

Would be covered under 7 AAC 105 – 7 AAC 160 if delivered in person; and
Is delivered in compliance with
- The same requirements of 7 AAC 105 – 7 AAC 160, including prior authorization requirements and service limitations, as if the service was delivered in person; and
- The requirements of AS 08.01, AS 08.68, AS 47.07, and 7 AAC 105 – 7 AAC 160, including the telehealth requirements and limitations of 7 AAC 110.620 – 7 AAC 110.639, as applicable to the service, the provider, and the mode of delivery.

SOURCE: AK Admin. Code, Title 7, 110.620. (Accessed Jun. 2024).

The department shall pay for all services covered by the medical assistance program provided through telehealth in the same manner as if the services had been provided in person, including

behavioral health services;
services covered under home and community-based waivers;
services covered under state plan options under 42 U.S.C. 1396-1396p (Title XIX, Social Security Act);
services provided by a community health aide or a community health practitioner certified by the Community Health Aide Program Certification Board;
services provided by a behavioral health aide or behavioral health practitioner certified by the Community Health Aide Program Certification Board;
services provided by a dental health aide therapist certified by the Community Health Aide Program Certification Board;
services provided by a chemical dependency counselor certified by a certifying entity for behavioral health professionals in the state specified by the department in regulation;
services provided by a rural health clinic or a federally qualified health center;
services provided by an individual or entity that is required by statute or regulation to be licensed or certified by the department or that is eligible to receive payments, in whole or in part, from the department;
services provided through audio, visual, or data communications, alone or in any combination, or through communications over the Internet or by telephone, including a telephone that is not part of a dedicated audio conference system, electronic mail, text message, or two-way radio;
assessment, evaluation, consultation, planning, diagnosis, treatment, case management, and the prescription, dispensing, and administration of medications, including controlled substances; and
services covered under federal waivers or demonstrations other than home and community-based waivers.

specifically excludes or limits the service from telehealth coverage or reimbursement by regulations adopted under this subsection;
determines, based on substantial medical evidence, that the service cannot be safely provided using telehealth or using the specified mode; or
determines that providing the service using the specified mode would violate federal law or render the service ineligible for federal financial participation under applicable federal law.

All services delivered through telehealth under this section must comply with the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191).

SOURCE: AK Statute Sec. 47.07.069, (Accessed Jun. 2024).

See list of telehealth services allowed in Alaska Medicaid’ temporary telehealth services fee schedule for FY 2024.

SOURCE: Alaska Medicaid, Telehealth Services: Temporary Fee Schedule, Effective 9/1/2023, (Accessed Jun. 2024).

Check behavioral health fee schedules and Section 1115 Medicaid Waiver Services Administrative Manuals for services allowed via telehealth.

SOURCE: Medicaid Provider Assistance Information, Division of Behavioral health, Fee Schedules [fee schedules listed at bottom of page], (Accessed Jun. 2024).

Eligible services:

An initial visit
One follow-up visit;
A consultation to confirm a diagnosis;
Diagnostic, therapeutic or interpretive service;
A psychiatric or substance abuse assessments;
Psychotherapy
Pharmacological management services on an individual recipient basis.

Note: Manual is under review.

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Physician, ARNP, PA Services (5/13), p. 31, (Accessed Jun. 2024).

Dental services do not require the use of the telemedicine modifier.

Note: Manual is under review.

SOURCE: AK Dept. of Health and Social Svcs. Dental Services. Tribal Services Manual (1/3/17), pg. 97, (Accessed Jun. 2024).

For patient-initiated online digital service, whether synchronous or asynchronous, the following are not reimbursable:

Nonevaluative or nonmanagement services including appointment scheduling and electronic communication of test results;
Provider-initiated online digital service;
Patient-initiated online digital service within the postoperative period of a completed procedure or within seven days of an in-person visit and related to the illness, injury, or other reason for that visit.

The department will not pay

for the use, or any costs associated with the use, of technological equipment and systems associated with the delivery of a service by means of a telehealth modality;
a provider for communication with that provider’s supervising provider or communication with a provider who is acting in a supervisory capacity;
a supervising provider or a provider who is acting in a supervisory capacity for communication with a supervisee or for review of a supervisee’s work;
a provider participating in a telehealth encounter whose sole purpose is to facilitate the telehealth encounter between the recipient and a rendering provider or a consulting provider;
for a failed or unsuccessful telehealth connection or transmission;
for the following services when provided by means of a telehealth modality::
- chiropractic services;
- dental services;
- private-duty nursing services;
- pharmacy dispensing services;
- durable medical equipment and related services;
- prosthetic and orthotic devices and related services;
- transportation services;
- accommodation services;
- personal care services;
- home health services;
- community First Choice services;
- home and community-based waiver services, except for
  - care coordination services under 7 AAC 130.240;
  - day habilitation services under 7 AAC 130.260;
  - employment services under 7 AAC 130.270; or
  - intensive active treatment services under 7 AAC 130.275;

long term services and supports targeted case management services, except for case management services provided under 7 AAC 128.010(b)(2).

SOURCE: AK Admin. Code, Title 7, 110. 625 & 635 (Accessed Jun. 2024).

Alaska Medicaid will not pay for

The use of telemedicine equipment and systems
Services delivered by telephone when not part of a dedicated audio conference system
Services delivered by facsimile
The following services provided by telemedicine application:
- Direct entry midwife
- Durable medical equipment (DME)
- End-stage renal disease
- Home and community-based waiver
- Personal care assistant
- Pharmacy
- Private duty nursing
- Transportation and accommodation
- Vision (includes visual care, dispensing, or optician services)

Note: Manual under review.

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Physician, ARNP and PA Services (5/13), pg. 31-32 (Jun. 2024).

The department will pay in accordance with 7 AAC 145.020 for a service delivered by means of a telehealth modality by a rendering provider or a consulting provider in accordance with 7 AAC 110.620 – 7 AAC 110.639 as set out under 7 AAC 145.020.

The department will pay a rendering provider or a consulting provider in the same manner as payment is made for the same service provided through in-person mode of delivery, not to exceed 100 percent of the rate established under 7 AAC 145.050.

SOURCE: AK Admin Code, Title 7, 145.270, (Accessed Jun. 2024).

The department will not pay a physician for experimental therapy, nonmedical outpatient therapy, or nonmedical counseling, including any of the following services:

interaction between recipient and provider by means of the Internet, except as provided in 7 AAC 110.620 — 7 AAC 110.639 for telehealth services.

SOURCE: Alaska Admin Code, Title 7, 110.445, (Accessed Jun. 2024).

Non-Emergency Medical Transportation and Escort Coverage

Clarifies types of services feasible for telehealth throughout the document.

SOURCE: Alaska Medicaid Policy Clarification Non-Emergency Medical Transportation, Sept. 18, 2023 (revised 11/29/23), (Accessed Jun. 2024).

Does Alaska Medicaid cover problem focused exams delivered through a telehealth modality?

Patient Initiated: Yes, service may be covered under CPT code 99441-99443.

Scheduled Visit or Provider Initiated: Yes, Problem focused evaluation and management services (CPT 99202-99205 and 99211-99215) are covered when delivered through Two-Way Audio-Video Technology or through store-and-forward.

Are therapy services (PT, OT, SLP) covered when delivered through a telehealth modality?

Yes: Therapy services (PT, OT, SLP) are covered when delivered through Two-Way Audio-Video Technology if the service is identified on the Telehealth Services Temporary Fee Schedule.

Use the same procedure codes as you would for an in-person encounter and apply a procedure modifier of either GT or 95.

Are initial hospital services reimbursable if performed via telehealth?

Yes: The professional component may be reimbursed using CPT codes 99221-99223 when services are delivered through Two-Way Audio-Video Technology.

Are initial nursing facility care services reimbursable if performed via telehealth?

Yes: The professional component may be reimbursed using CPT codes 99304-99306 when services are delivered through Two-Way Audio-Video Technology.

Can ventilator management services be conducted via a telehealth mode of delivery?

Yes: Ventilator management is reimbursable when performed via telehealth. Only the healthcare provider managing the ventilator may be reimbursed for ventilator management; any bedside adjustments are not separately reimbursable.

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023, (Accessed Jun. 2024).

DME Oxygen Guidelines and Concerns

Telehealth is included of definition of face-to-face encounter between the treating practitioner and the beneficiary and the encounter must be used for the purpose of gathering subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.

SOURCE: Alaska Dep. of Health, Letter to DME Providers, RE Review of Oxygen Guidelines and Concerns, Dec. 29, 2023, (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

Subject to the requirements of 7 AAC 110.620 – 7 AAC 110.639, to be eligible for payment under 7 AAC 105 – 7 AAC 160 for providing a service by means of a telehealth modality, a provider must meet the following requirements:

the provider must have an active license under AS 08 or AS 47, an active certification in the state, or an active license under the applicable laws of the jurisdiction in which the provider is located;
the provider must be enrolled under 7 AAC 105.210;
the provider, if licensed under AS 08 and required under 12 AAC 02.600, must be registered under 12 AAC 02.600 (telemedicine business registry);
the service must be delivered within the rendering provider’s, and if applicable, consulting provider’s scope of licensure or certification;
a claim submitted to the department must include applicable telehealth modifiers and place-of-service coding;
if the rendering provider or consulting provider determines, during a telehealth encounter, that a service extends beyond the scope of that provider’s license or certification, the provider must discontinue the encounter and refer the recipient to an appropriate provider; the rendering provider or consulting provider may bill only for the portion of the encounter that was within that provider’s scope of license or certification and only if the rendered portion of the encounter met all criteria of a separately billable service;
except as otherwise provided in 7 AAC 105 – 7 AAC 160, a recipient must be present during and participate in a telehealth encounter;
the provider must comply with all record keeping requirements set out under 7 AAC 105.230 for all telehealth services rendered;
the rendering provider and consulting provider, when delivering a service by means of a synchronous telehealth modality, must annotate the patient’s clinical record with the method of delivery, the recipient’s location during the delivery of the service, and confirmation that the recipient has consented to a telehealth method of delivery.

SOURCE: AK Admin. Code, Title 7, 110. 630 (Accessed Jun. 2024).

How do I bill for a services when a telehealth modality was used?

Procedure Code Modifier:

Two-Way Audio-Video Technology: GT or 95
Store-and-Forward: GQ
Two-Way Audio Only Technology : FQ and 93

Procedure Codes Defined as Audio Only: Failure to include either modifier FQ or modifier 93 will result in denial of payment for audio only services.

Patient Initiated Online Digital Services: Do not use telehealth modifiers when billing CPT codes 98970 – 98972 and 99421 – 99423.

Telehealth for Acute Stroke: Use procedure code modifier G0 (G-Zero) and the appropriate telehealth modifier (GT, 95, GQ, or FQ).

Helpful Hint: Modifier G0 (G-Zero) often gets confused with GO (G-Oh). Please ensure the appropriate modifier is utilized when billing either G0 (G-Zero) or GO (G-Oh).

Are services provided by therapy assistants covered when provided via a telehealth modality?

Yes: Services provided by enrolled physical and occupational therapy assistant and speech language pathology assistant are covered to the same extent as the supervising therapist.

Are outpatient rehabilitation Hospitals able to bill telehealth for therapy services (OT, PT, SLP) using a UB-04 or 837I and are there any additional requirements for identifying the claim as a telehealth claim?

Yes: Therapy services provided in an outpatient rehabilitation hospital setting are covered when delivered through Two-Way Audio-Video Technology for services identified on the Telehealth Services Temporary Fee Schedule.

Additional Requirements: Effective for dates of service on and after 7/1/2023, claims submitted with therapy revenue codes 042X, 043X, and 044X will require an appropriate CPT/HCPCS procedure code in form locater 44, HCPCS/Accommodation Rates/HIPPS Rate Codes.

Can direct entry midwives provide telehealth services?

Yes: Effective 9/1/2023 services provided by direct entry midwives are covered if identified on the Telehealth Services Temporary Fee Schedule.

Can optometrists provide telehealth services?

Yes: Effective 9/1/2023 services provided by optometrists are covered if identified on the Telehealth Services Temporary Fee Schedule.

Do I need to register with the Telemedicine Business Registry to offer telehealth services?

Yes, in most cases: All businesses engaged in or planning to engage in distance delivery of health care to a patient located in Alaska must register with the state’s Telemedicine Business Registry. Providers who are an employee of a business do not need to register.

Providers subject to Telemedicine Business Registry requirements:

Alaska-licensed audiologist or speech-language pathologist; behavior analyst; chiropractor; professional counselor; dentist or dental hygienist; dietitian or nutritionist; naturopath; marital and family therapist; physician, podiatrist, osteopath, or physician assistant; direct-entry midwife; nurse or advanced practice registered nurse (APRN); dispensing optician; optometrist; pharmacist; physical therapist or occupational therapist; psychologist or psychological associate; social worker; or a physician licensed in another state.
* This information is based off of May 22nd, 2023, DCCED publication. See DCCED’s Telehealth Information Webpage for updates.

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023, (Accessed Jun. 2024).

The department shall pay for all services covered by the medical assistance program provided through telehealth if the department pays for those services when provided in person, including:

…

services provided by a community health aide or a community health practitioner certified by the Community Health Aide Program Certification Board;
services provided by a behavioral health aide or behavioral health practitioner certified by the Community Health Aide Program Certification Board;
services provided by a dental health aide therapist certified by the Community Health Aide Program Certification Board;
services provided by a chemical dependency counselor certified by a certifying entity for behavioral health professionals in the state specified by the department in regulation;
services provided by a rural health clinic or a federally qualified health center;
services provided by an individual or entity that is required by statute or regulation to be licensed or certified by the department or that is eligible to receive payments, in whole or in part, from the department;

SOURCE: AK Statute Sec. 47.07.069, (Accessed Jun. 2024).

The role of the provider falls into three categories:

Referring Provider: Evaluates a patient, determines the need for a consultation, and arranges services of a consulting provider for the purpose of diagnosis and treatment.
Presenting Provider: Introduces a patient to the consulting provider during an interactive telemedicine session (may assist in the telemedicine consultation).
Consulting Provider: Evaluates the patient and/or medical data/images using telemedicine mode of delivery upon recommendation of the referring provider.

NOTE: Manual is under review.

SOURCE: AK Dept. of Health and Social Svcs. Billing for Telemedicine Services. Section II: Professional Claims Management, Feb. 6, 2020 (section revised 6/12), pg. 20, (Accessed Jun. 2024).

Mental Health

An entity designated by the department under AS 47.30.520 — 47.30.620 may provide community mental health services authorized under AS 47.30.520 — 47.30.620 through telehealth to a patient in this state.

If an individual employed by an entity designated by the department under AS 47.30.520 — 47.30.620, in the course of a telehealth encounter with a patient, determines that some or all of the encounter will extend beyond the community mental health services authorized under AS 47.30.520 — 47.30.620, the individual shall advise the patient that the entity is not authorized to provide some or all of the services to the patient, recommend that the patient contact an appropriate provider for the services the entity is not authorized to provide, and limit the encounter to only those services the entity is authorized to provide. The entity may not charge a patient for any portion of an encounter that extends beyond the community mental health services authorized under AS 47.30.520 — 47.30.620.

A fee for a service provided through telehealth under this section must be reasonable and consistent with the ordinary fee typically charged for that service and may not exceed the fee typically charged for that service.

An entity permitted to provide telehealth under this section may not be required to document a barrier to an in-person visit to provide health care services through telehealth. The department may not limit the physical setting from which an entity may provide health care services through telehealth.

Nothing in this section requires the use of telehealth when an individual employed by an entity designated by the department under AS 47.30.520 — 47.30.620 determines that providing services through telehealth is not appropriate or when a patient chooses not to receive services through telehealth.

SOURCE: AK Statute Sec. 47.30.585, (Accessed Jun. 2024).

Uniform Alcoholism and Intoxication Treatment

A public or private treatment facility approved under AS 47.37.140 may provide health care services authorized under AS 47.37.030 — 47.37.270 through telehealth to a patient in this state.

If an individual employed by a public or private treatment facility approved under AS 47.37.140, in the course of a telehealth encounter with a patient, determines that some or all of the encounter will extend beyond the health care services authorized under AS 47.37.030 — 47.37.270, the individual shall advise the patient that the facility is not authorized to provide some or all of the services to the patient, recommend that the patient contact an appropriate provider for the services the facility is not authorized to provide, and limit the encounter to only those services the facility is authorized to provide. The facility may not charge a patient for any portion of an encounter that extends beyond the health care services authorized under AS 47.37.030 — 47.37.270.

A facility permitted to practice telehealth under this section may not be required to document a barrier to an in-person visit to provide health care services through telehealth. The department may not limit the physical setting from which a facility may provide health care services through telehealth.

Nothing in this section requires the use of telehealth when an individual employed by a facility approved under AS 47.37.140 determines that providing services through telehealth is not appropriate or when a patient chooses not to receive services through telehealth.

SOURCE: AK Statute Sec. 47.37.145, (Accessed Jun. 2024).

Various services are allowed via telehealth for Alaska Behavioral Health and Substance Use Disorder (SUD) Providers. See manuals.

SOURCE: State of Alaska Department of Health and Social Services Division of Behavioral Health Services, Alaska Behavioral Health Providers Services Standards & Administrative Procedures for Behavioral Health Provider Services & SUD Services [see both documents], (Accessed Jun. 2024).

Stand-alone vaccine counseling may be covered when provided via telehealth if the appropriate telehealth modifier and place of service are reported on the claim.

Stand-alone vaccine counselling, rendered in person or telehealth, is not separately reimbursable if the vaccine associated with the counselling is administered within one month of counseling.

SOURCE: Alaska Medicaid Provider Billing Manual, Immunization Services, pg. 12, (Accessed Jun. 2024).

Tribal FQHC

Will my facility be able to continue to provide telemedicine (video-audio synchronous) and telephonic (audio-only) behavioral health services as a Tribal FQHC?

Refer to the most current guidance document on telehealth: https://extranetsp.dhss.alaska.gov/hcs/medicaidalaska/Provider/Updates/20230919_Telehealth_FAQs.pdf.

Telehealth Services. Will my facility be able to provide telemedicine (video-audio synchronous), telephonic (audio-only), and store and forward telehealth services and be reimbursed for those services as a Tribal FQHC?

Yes, telehealth services regulations were effective 9/1/2023. Refer to the most current guidance on telehealth services: https://extranetsp.dhss.alaska.gov/hcs/medicaidalaska/Provider/Sites/Telehealth.html

Can a Tribal FQHC provide services off-site after February 11, 2025?

Yes, please refer to telehealth regulations that were effective 9/1/2023 https://aws.state.ak.us/OnlinePublicNotices/Notices/Attachment.aspx?id=142671

SOURCE: Alaska Medicaid, FAQs on Tribal FQHCs, (Accessed Jun. 2024).

This manual includes information about Alaska Medical Assistance for the following types of providers and services:

Telemedicine

Dental telemedicine services do not require use of the telemedicine modifier.

SOURCE: State of Alaska Department of Health and Social Services Division, Alaska Medical Assistance Provider Billing Manual, Tribal Facility Services, Policies and Procedures, Feb. 18, 2021, (Accessed Jun. 2024).

ELIGIBLE SITES

How do I bill for a services when a telehealth modality was used?

Place of Service Code:

Place of Service Code 02: Telehealth- member not located at home during encounter
Place of Service Code 10: Telehealth – member is located at home during encounter

SOURCE: Alaska Medicaid Frequently Asked Questions Coverage of Telehealth Modalities, Sept. 19, 2023, (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

No reference found.

FACILITY TRANSMISSION FEE

The department will not pay

for the use, or any costs associated with the use, of technological equipment and systems associated with the delivery of a service by means of a telehealth modality;
a provider for communication with that provider’s supervising provider or communication with a provider who is acting in a supervisory capacity;
a supervising provider or a provider who is acting in a supervisory capacity for communication with a supervisee or for review of a supervisee’s work;
a provider participating in a telehealth encounter whose sole purpose is to facilitate the telehealth encounter between the recipient and a rendering provider or a consulting provider;
for a failed or unsuccessful telehealth connection or transmission

SOURCE: AK Admin. Code, Title 7, 110.635. (Accessed Jun. 2024).

READ LESS

Arizona

Last updated 05/29/2024

POLICY

Fee-for-Service Provider Manual

AHCCCS covers medically necessary, non-experimental and …

POLICY

Fee-for-Service Provider Manual

AHCCCS covers medically necessary, non-experimental and cost-effective services provided via telehealth. There are no geographic restrictions for telehealth; services delivered via telehealth are covered by AHCCCS in rural and metropolitan regions.

Telehealth may include healthcare services delivered via asynchronous (store and forward), remote patient monitoring, teledentistry, or telemedicine (interactive audio and video).

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/2024), pg. 48, & IHS/Tribal Provider Billing Manual, (5/2/2024), pg. 52 (Accessed May 2024).

The Contractor and FFS programs shall cover medically necessary, non-experimental, and cost effective services delivered via Telehealth by AHCCCS registered providers for AHCCCS covered services.

This Policy applies to ACC, ACC-RBHA, ALTCS E/PD, DCS/CHP (CHP), and DES/DDD (DDD) Contractors; Fee-For-Service (FFS) Programs including: the American Indian Health Program (AIHP), DES/DDD Tribal Health Program (DDD THP), Tribal ALTCS, TRBHA; and all FFS populations, excluding Federal Emergency Services (FES). (For FES, refer to AMPM Chapter 1100). This Policy establishes the requirements regarding telehealth.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Medical Policy for AHCCCS Covered Services, Ch. 300, (320-I (Services with Special Circumstances) pg. 1). Approved 8/29/23. (Accessed May 2024).

ELIGIBLE SERVICES/SPECIALTIES

Some of the services that can be covered via real-time telehealth include, but are not limited to:

Behavioral Health
Cardiology
Dentistry
Dermatology
Endocrinology
Hematology/Oncology
Home Health
Infectious Diseases
Inpatient Consultations
Medical Nutrition Therapy (MNT)
Neurology
Obstetrics/Gynecology
Oncology/Radiation
Ophthalmology
Orthopedics
Office Visits (adult and pediatric)
Outpatient Consultations
Pain Clinic
Pathology & Radiology
Pediatrics and Pediatric Subspecialties
Pharmacy Management
Rheumatology
Surgery Follow-Up and Consultations

Behavioral health services are covered for all Medicaid-eligible AHCCCS beneficiaries and KidsCare members.

Covered behavioral health services can include, but are not limited to:

Diagnostic consultation and evaluation,
Psychotropic medication adjustment and monitoring,
Individual and family counseling, and
Case management.

For a complete code set of services, along with their eligible place of service and modifiers, that can be billed as telehealth please visit the AHCCCS Medical Coding Resources webpage.

For real time behavioral health services, the member’s physician, case manager, behavioral health professional, or tele-presenter may be present with the member during the consultation, but their presence is not required.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/2024), pg 50 -51; IHS/Tribal Provider Billing Manual, Ch. 8 Individual Practitioner Services, (5/2/24), pg. 52-54 (Accessed May 2024).

Prolonged preventive services, beyond the typical service of the primary procedure, that require direct patient contact and occur in either the office or another outpatient setting are covered under telehealth. See manual for example codes.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Manual, Ch. 10: Individual Practitioner Services, (5/2/2024), pg. 51, (Accessed May 2024).

AHCCCS Policy Manual

The Contractor and FFS programs may not limit or deny the coverage of services provided through Telehealth and may apply only the same limits or exclusions on a service provided through Telehealth that are applicable to an in-person encounter for the same service, except for services for which the weight of evidence, based on practice guidelines, peer-reviewed clinical publications or research or recommendations by the Telehealth advisory committee on Telehealth best practices established by A.R.S. § 36-3607, determines not to be appropriate to be provided through Telehealth.

Services delivered via Telehealth shall not replace member or provider choice for healthcare delivery modality. As specified in A.R.S. § 36-3605i , a provider shall make a good faith effort in determining both of the following:

Whether a service should be provided through Telehealth instead of in-person. The provider shall use clinical judgment in considering whether the nature of the services necessitates physical interventions and close observation and the circumstances of the member, including diagnosis, symptoms, history, age, physical location and access to telehealth; and
The communication medium of Telehealth and, whenever reasonably practicable, the telehealth communication medium that allows the provider to most effectively assess, diagnose and treat the member. Factors the provider may consider in determining the communication medium include the member’s lack of access to or inability to use technology or limits in telecommunication infrastructure necessary to support interactive Telehealth encounters.

Telemedicine services include health care delivery, diagnosis, consultation, treatment, and the transfer of medical data through real-time synchronous interactive audio and video communications that occur in the physical presence of the member.

The Contractor and FFS Programs shall reimburse providers at the same level of payment for equivalent services as identified by Healthcare Common Procedure Coding System (HCPCS) whether provided via telemedicine or in-person office/facility setting.

The AHCCCS Telehealth code set defines which codes are billable as a Telemedicine service and the applicable modifier(s) and place of service providers must use when billing for a service provided via Telemedicine.

Refer to the AHCCCS coding webpage for coding requirements for Telehealth services, including applicable modifiers and POS available:
https://www.azahcccs.gov/PlansProviders/MedicalCodingResources.html

AHCCCS covers Teledentistry for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) aged members when provided by an AHCCCS registered dental provider. Refer to AMPM Policy 431 for more information on oral health care for EPSDT aged members including covered dental services.

Teledentistry includes the provision of preventative and other approved therapeutic services by the AHCCCS registered Affiliated Practice Dental Hygienist, who provides dental hygiene services under an affiliated practice relationship with a dentist. Refer to AMPM Policy 431 for information on Affiliated Practice Dental Hygienist.

Teledentistry does not replace the dental examination by the dentist. Limited exams may be billed through the use of Teledentistry. Periodic and comprehensive examinations cannot be billed through the use of teledentistry alone.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 1-2 & 4-5), Approved 8/29/23. (Accessed May 2024)

In addition to services provided pursuant to section 36-2907, subsection A, paragraph 7, the Arizona health care cost containment system administration shall implement teledentistry services for enrolled members who are under twenty-one years of age.

SOURCE: AZ Statute, Sec. 36-2907.13. (Accessed May 2024).

Remote Monitoring:

G2010 – Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
G2012 – Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

SOURCE: AZ Administrative Code Title 20, Ch. 5, pg. 402. (Accessed May 2024).

Home Health Services

A Face-To-Face visit, in person or via telehealth, with a member’s PCP or non-physician practitioner, related to the primary reason the member requires home health services [42 CFR 440.70].

The Face-to-Face encounter may occur through telehealth.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Home Health Services, Ch 211, (pg. 1 & 5), Approved 12/16/21. & FFS Manual, Home Health, Ch. 20, Revised 10/1/18, pg. 2, & IHS/Tribal Billing Manual, Ch. 13 Home Health, (Revised 10/1/18) pg. 2, (Accessed May 2024).

Medical Equipment, Medical Appliances and Medical Supplies

The face-to-face encounter may occur through telehealth.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Medical Equipment, Medical Appliances and Medical Supplies, Ch 310-P, (pg. 3), Approved 6/6/23 & FFS Billing Manual, Ch. 13, .pg 4, (Revised 5/31/23), (Accessed May 2024).

Transportation

Treatment on scene may also be performed, when medically indicated, via a telehealth visit performed in accordance with AMPM Policy 320-I.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Transportation, Ch 310-BB, (pg. 4), Approved 4/7/22. (Accessed May 2024).

To initiate and facilitate a members’ receipt of medically necessary covered service(s) by a Qualified Health Care Partner at the scene of a 9-1-1 response either in-person on the scene or via telehealth (Treatment in Place).

SOURCE: FFS Billing Manual, Ch. 14, .pg 7, (Revised 1/30/23), & IHS/Tribal Billing Manual, Ch. 11, (Revised 6/16/23) pg. 7, (Accessed May 2024).

Therapeutic Foster Care for Children (TFC)

TFC visits may occur in-person or via telemedicine (i.e. interactive audio/video communications).

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Therapeutic Foster Care for Children, Ch 320-W, (pg. 8), Approved 7/7/22. (Accessed May 2024).

Out-Of-State Placements for Behavioral Health Treatment

When appropriate, the member/Health Care Decision Maker and designated representative is involved throughout the duration of the placement. This may include family counseling in-person or by telemedicine.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Out-Of-State Placements for Behavioral Health Treatment, Ch 450, (pg. 4), Approved 6/18/20. (Accessed May 2024).

ELIGIBLE PROVIDERS

Fee-for-Service Provider Manual & IHS/Tribal Provider Billing Manual

Telehealth, including Teledentistry services, may be provided by AHCCCS registered providers, within their scope of practice.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/24), pg. 51, & IHS/Tribal Provider Billing Manual (5/2/24), pg. 55. (Accessed May 2024).

For Reimbursement at the A–R – Revenue Codes 0510, 0512 and 0516 may be submitted to AHCCCS on a UB-04 claim form. To indicate that the clinic visit (0510), a dental visit (0512) or urgent clinic visit (0516) was done via telehealth a modifier (GT or GQ) shall be included on the claim.

For Reimbursement at the Capped FFS Rate or APM Ra–e – For a complete code set of services, along with their eligible place of service and modifiers that can be billed as telehealth, please visit the AHCCCS Medical Coding Resources web page at: https://www.azahcccs.gov/PlansProviders/MedicalCodingResources.html

SOURCE: AZ Health Care Cost Containment System, AHCCCS IHS/Tribal Provider Billing Manual (5/2/24), pg. 55. (Accessed May 2024).

Telehealth and telemedicine may qualify as an FQHC/RHC visit if it meets the requirements specified in AMPM 320-I, Telehealth and Telemedicine. To qualify as a reimbursable telehealth visit, claims with procedure code T1015 must additionally include another eligible code from the AHCCCS Telehealth Code Set.

SOURCE: AZ Health Care Cost Containment System, AHCCCS. Provider Qualifications and Provider Requirements. Ch. 600, Oct. 2015, pg. 3 & AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Addendum FQHC/RHC, (8/25/2022), pg. 3, (Accessed May 2024).

Telehealth may qualify as a Federally Qualified Healthcare Center/Rural Health Clinic (FQHC/RHC) visit, if all other applicable conditions in this Policy are met. Refer to AMPM Policy 670.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 5), Approved 8/29/23, (Accessed May 2024).

School Based Claiming Program

For DSC services provided via telehealth, all providers shall be an AHCCCS registered provider and licensed in Arizona by the governing board for the profession or specialty or may provide services via telehealth if all requirements for the provision of telehealth are met, including board registration as specified in A.R.S § 36-3606 and AMPM Policy 320-I.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. School Based Claiming Program Ch 700, (710 pg. 3), Approved 8/3/21. (Accessed May 2024).

ELIGIBLE SITES

The Place of Service (POS) listed on the CMS 1500 claim form shall be the originating site (where the AHCCCS member is located or where the asynchronous service originates).

For Medicare Dual members, claims may be submitted with the POS listed as 02 (Telemedicine) to comply with Medicare guidelines. The POS 02 (Telemedicine) will designate the service being provided as a telehealth service.

Fee-for-Service Provider Manual definitions:

Distant site means “the site at which the provider delivering the service is located at the time the service is provided via telehealth.”

Originating site means “the location of the AHCCCS member at the time the service is being furnished via telehealth or where the asynchronous service originates. This is considered the place of service.”

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For- Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/24), pg. 50 & IHS/Tribal Provider Billing Manual, (5/2/24). pg. 54 (Accessed May 2024).

There are no Place Of Service (POS) restrictions for distant site.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 5), 8/29/23. (Accessed May 2024).

GEOGRAPHIC LIMITS

There are no geographic restrictions for telehealth. Services delivered via telehealth are covered by AHCCCS in rural and urban/metropolitan regions.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 1), Approved 8/29/23 ; AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/24), pg. 48, & IHS/Tribal Provider Billing Manual, (5/2/24), pg. 52. (Accessed May 2024).

FACILITY/TRANSMISSION FEE

No Reference Found

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Arkansas

Last updated 05/27/2024

POLICY

Arkansas Medicaid provides payment to a licensed or certified …

POLICY

Arkansas Medicaid provides payment to a licensed or certified healthcare professional or a licensed or certified entity for services provided through telemedicine if the service provided through telemedicine is comparable to the same service provided in-person.

Coverage and reimbursement for services provided through telemedicine will be on the same basis as for services provided in-person. While a distant site facility fee is not authorized under the Telemedicine Act, if reimbursement includes payment to an originating site (as outlined in the above paragraph), the combined amount of reimbursement to the originating and distant sites may not be less than the total amount allowed for healthcare services provided in-person.

SOURCE: AR Medicaid Provider Manual. Section I General Policy. Rule 105.190. p. I-13 Updated Jan. 1, 2022 (Accessed May 2024).

Arkansas Medicaid shall provide payment for telemedicine healthcare services to licensed or certified healthcare professionals or entities that are authorized to bill Arkansas Medicaid directly for healthcare services. Coverage and reimbursement for healthcare services provided through telemedicine shall be reimbursed on the same basis as healthcare services provided in person.

SOURCE: Section III Billing Documentation. Rule 305.000. , p. III-8 Updated Jan. 1, 2022. (Accessed May 2024).

Rural Health Centers

In order for a telemedicine encounter to be covered by Medicaid, the practitioner and the patient must be able to see and hear each other in real time.

SOURCE: AR Medicaid Provider Manual. Section II Rural Health. Rule 211.300. p. II-6 Updated 2/1/24. (Accessed May 2024).

Occupational Therapy, Physical Therapy and Speech-Language Pathology Services

An enrolled provider may be reimbursed for medically necessary occupational therapy, physical therapy, and speech-language pathology services delivered through telemedicine.

The service provider is responsible for ensuring service delivery through telemedicine is equivalent to in-person, face-to-face service delivery.

The service provider is responsible for ensuring the calibration of all clinical instruments and the proper functioning of all telecommunications equipment.
All services delivered through telemedicine must be delivered in a synchronous manner, meaning through real-time interaction between the practitioner and client via a telecommunication link.
A store and forward telecommunication method of service delivery where either the client or practitioner records and stores data in advance for the other party to review at a later time is prohibited, although correspondence, faxes, emails, and other non-real time interactions may supplement synchronous telemedicine service delivery.

Services delivered through telemedicine are reimbursed in the same manner and subject to the same benefit limits as in-person, face-to-face service delivery. View or print the billable telecommunication codes and descriptions.

SOURCE: AR Medicaid Provider Manual. Section II Occupational Therapy, Physical Therapy and Speech-Language Pathology Services, Rule 214.600. Updated Jan. 1, 2022, (Accessed May 2024).

ELIGIBLE SERVICES/SPECIALTIES

A health benefit plan [includes Arkansas Medicaid] shall provide coverage and reimbursement for healthcare services provided through telemedicine on the same basis as the health benefit plan provides coverage and reimbursement for health services provided in person, unless this subchapter specifically provides otherwise.

A health benefit plan is not required to reimburse for a healthcare service provided through telemedicine that is not comparable to the same service provided in person.

SOURCE: AR Code 23-79-1602(c). (Accessed May 2024).

Covered counseling services are outpatient services. Specific Counseling Services are available to inpatient hospital patients (as outlined in Sections 240.000 and 220.100), through telemedicine, and to nursing home residents. Counseling Services are billed on a per unit or per encounter basis as listed. All services must be provided by at least the minimum staff within the licensed scope of practice to provide the service.

Telemedicine is listed as an allowed delivery mode for certain services throughout the Counseling Services Manual (formerly the Outpatient Behavioral Health Services manual).

SOURCE: AR Medicaid Manual, Section II Counseling Services, Updated Apr. 1, 2024, (Accessed May 2024).

Occupational Therapy, Physical Therapy and Speech-Language Pathology Services

An enrolled provider may be reimbursed for medically necessary occupational therapy, physical therapy, and speech-language pathology services delivered through telemedicine.

Occupational therapy, physical therapy, and speech-language pathology evaluation and treatment planning services may not be conducted through telemedicine and must be performed through traditional in-person methods.

SOURCE: AR Medicaid Provider Manual. Section II Occupational Therapy, Physical Therapy and Speech-Language Pathology Services, Rule 214.600. Updated Jan. 1, 2022, (Accessed May 2024).

Rural Health Centers

Arkansas Medicaid covers RHC encounters and two ancillary services (fetal echography and echocardiography) as “telemedicine” services.

Arkansas Medicaid defines telemedicine services as medical services performed as electronic transactions in real time. In order for a telemedicine encounter to be covered by Medicaid, the practitioner and the patient must be able to see and hear each other in real time. Physician interpretation of fetal ultrasound is covered as a telemedicine service if the physician views the echography or echocardiography output in real time while the patient is undergoing the procedure.

SOURCE: AR Medicaid Provider Manual. Section II Rural Health. Rule 211.300. Updated 2/1/24. (Accessed May 2024).

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

Virtual services can be provided using mobile secure telecommunication devices, electronic monitoring equipment and include clinical provider care, behavioral health therapies, speech, occupational and physical therapy services, and treatment provided to an individual at their residence. Virtual provider services may use various evidence-based and innovative independence at-home strategies. They may include the provision of on-going care management, remote telehealth monitoring and consultation, face to face or through the use secure web-based communication and mobile telemonitoring technologies to remotely monitor and evaluate the patient’s functional and health status. Virtual and telehealth services are provided in lieu of providing the same services at a practice site or provided at the individual’s place of residence.

SOURCE: PASSE Program, Section. II, p. 8, (1/1/23). (Accessed May 2024).

A healthcare professional may use telemedicine to perform group meetings for healthcare services, including group therapy.

Telemedicine for group therapy provided to adults who are participants in a program or plan authorized and funded under 42 U.S.C. § 1396a, as approved by the United States Secretary of Health and Human Services, may only be permitted if the Centers for Medicare and Medicaid Services allows telemedicine for group therapy provided to adults.

Telemedicine shall not be used for group therapy provided to a child who is eighteen (18) years of age or younger.

SOURCE: AR CODE 17-80-404 (Accessed May 2024).

Home Health

The face-to-face encounter may occur through telemedicine when applicable to the program manual of the performing provider of the encounter.

SOURCE: AR Medicaid Provider Manual. Section II Nurse Practitioner. Rule 203.020, II-7. Updated 1/1/24 (Section updated 7-1-17) & AR Medicaid Provider Manual. Section II Home Health. Rule 206.000, II-5. Section updated July 1, 2017 (overall manual updated 1/1/24), & AR Medicaid Provider Manual. Section II Certified Nurse-Midwife. Rule 204.101, II-6. Section updated July 1, 2017. (Overall manual updated 1/1/24, (Accessed May 2024).

Behavioral Health Conditions and Services

Screening for behavioral health conditions and behavioral health services as described in subsection (a) of this section may be provided via telemedicine and reimbursed by the Arkansas Medicaid Program as required under § 20-77-141.

SOURCE: AR Code 20-77-149, (Accessed May 2024).

Ambulance Services – Newly Passed Legislation

An ambulance service’s operators may triage and transport a patient to an alternative destination in this state or treat in place if the ambulance service is coordinating the care of the patient through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.

SOURCE: AR Code 20-13-108, (Accessed May 2024).

On and after January 1, 2024, a healthcare insurer [includes Medicaid] that offers, issues, or renews a health benefit plan in this state shall provide coverage for:

An ambulance service to:
- Treat an enrollee in place if the ambulance service is coordinating the care of the enrollee through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or
- Triage or triage and transport an enrollee to an alternative destination if the ambulance service is coordinating the care of the enrollee through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or

An encounter between an ambulance service and enrollee that results in no transport of the enrollee if:
- The enrollee declines to be transported against medical advice; and
- The ambulance service is coordinating the care of the enrollee through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.

See statute for additional restrictions.

The reimbursement rate for an ambulance service whose operators triage, treat, and transport an enrollee to an alternative destination, or triage, treat, and do not transport an enrollee if the enrollee declines to be transported against medical advice, if the ambulance service is coordinating the care of the enrollee through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint under this section shall be at least at the rate:

Contracted with a local government entity where the alternative destination is located; or
Established by the Workers’ Compensation Commission under its schedule for emergency Advance Life Support Level 1.

SOURCE: AR Code 23-79-2703, (Accessed May 2024).

Ground ambulance triage, treat, and transport to alternative location/destination services (T3AL) may be covered only when provided by an ambulance company that is licensed and is an enrolled provider in the Arkansas Medicaid Program. An ambulance service may triage and transport a beneficiary to an alternative destination or treat in place if the ambulance service is coordinating the care of the beneficiary through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint. Telemedicine rules are described in Section 105.190 and must be followed unless instructions are given within Section II of the prevailing Medicaid manual. The use of audio-only electronic technology is not allowed for T3AL services.

For the purposes of T3AL, a behavioral health specialist is a board-certified psychiatrist or an Independently Licensed Practitioner who can provide counseling services to Medicaid beneficiaries in the Outpatient Behavioral Health program.

SOURCE: AR Medicaid Provider Manual. Section II Transportation. Rule 214.100, II-7 to 8. Updated 2/1/24, (Accessed May 2024).

Group Therapy – General Professional Requirement (Not Medicaid exclusive)

A healthcare professional may use telemedicine to perform group meetings for healthcare services, including group therapy.

Telemedicine shall not be used for group therapy provided to a child who is eighteen (18) years of age or younger.

SOURCE: AR CODE 17-80-404 (Accessed May 2024).

Life360 HOMES

The Rural Life360 will provide the following care coordination supports: … Provide intensive care coordination and coaching supports for enrolled clients. Intensive care coordination and coaching include: … Providing supports through any of the following:

Home visits in such frequency as is necessary to assist the client meet his/her documented PCAP goals
Office visits
Video-supported visits
Telephone or text message contacts in conjunction with in-person visits

SOURCE: AR Medicaid Provider Manual. Section II Life360 HOMES. Rule 210.500 & 210.600, Updated 11-1-23. (Accessed May 2024).

AR Independent Assessment (ARIA)

Behavioral Health Services:

A reassessment will be completed by staff employed by the independent assessment contractor utilizing the current approved assessment instrument (ARIA), which was approved prior to April 1, 2021, to assess functional need. An interview will be conducted in person for initial assessments, with the option of using telemedicine to complete Behavioral Health reassessments. The telemedicine tool must meet the 1915(i) requirement for the use of telemedicine under 42 CFR 441.720 (a)(1)(i)(A) through (C).

To continue to receive Complex Care services, members must receive a complex care assessment annually and be assessed as needing Complex Care services. A reassessment will be completed by appropriate DHS-approved staff using the appropriate Complex Care assessment tool. If a member does not meet the need for Complex Care services, the member will be placed back in Tier 3. An in-person interview will be conducted for initial assessments, with the option of using telemedicine to complete reassessments for members who meet the criteria for Complex Care. The telemedicine tool must meet the 1915(i) requirement for the use of telemedicine under 42 CFR 441.720 (a)(1)(i)(A) through (C).

SOURCE: AR Medicaid Provider Manual, Section II, AR Independent Assessment (ARIA), 210.100 & .600, 1-1-24, (Accessed May 2024).

Life Choices Lifeline and Continuum of Care Program

The purpose of the Life Choices Lifeline and Continuum of Care Program is to provide a statewide telemedicine network and care program to provide community outreach, direct services, support, social services case management, care coordination, consultation, and referrals to:

Encourage healthy childbirth;
Support childbirth as an alternative to abortion;
Promote family formation;
Aid in successful parenting;
Assist parents in establishing successful parenting techniques; and
Increase families’ economic self-sufficiency.

SOURCE: AR Rules for Life Choices Lifeline and Continuum of Care Program, Sec. 102, (Lexis Nexis: 016 Dep of Human Services, 29 Div. of Medical Services, 009 Developmental Screens for Children), (Accessed May 2024).

Covered EIDT services are clinic-based services and cannot be delivered through telemedicine or at any location other than the licensed EIDT facility.

SOURCE: AR Rules and Regulations, Sec. 016.05.24-002, & AR Medicaid Provider Manual. Section II EIDT. Rule 221.000. Updated 4-1-24 (Accessed May 2024).

ELIGIBLE PROVIDERS

The distant site is the location of the healthcare provider delivering telemedicine services.

SOURCE: Section III Provider Billing Documentation. Rule 305.000. Updated Jan. 1, 2022 (Accessed May 2024).

Services at the distant site must be provided by an enrolled Arkansas Medicaid Provider who is authorized by Arkansas law to administer healthcare.

The professional or entity at the distant site must be an enrolled Arkansas Medicaid Provider.

SOURCE: AR Medicaid Provider Manual. Section I General Policy. Rule 105.190. Updated Jan. 1, 2022 & Section III Billing Documentation. Rule 305.000. Updated Jan. 1, 2022, (Accessed May 2024).

The provider of the distant site must submit claims for telemedicine services using the appropriate CPT or HCPCS code for the professional service delivered. The provider must use Place of Service two (02) (telemedicine distant site) when billing the CPT or HCPCS codes.

SOURCE: AR Medicaid Provider Manual. Section III Billing Documentation. Rule 305.000. Updated Jan. 1, 2022. (Accessed May 2024)

The distant site healthcare provider will not utilize telemedicine services with a client unless a professional relationship exists between the provider and the client. A professional relationship exists when, at a minimum:

The healthcare provider has previously conducted an in-person examination of the client and is available to provide appropriate follow-up care;
The healthcare provider personally knows the client and the client’s health status through an ongoing relationship and is available to provide follow-up care;
The treatment is provided by a healthcare provider in consultation with, or upon referral by, another healthcare provider who has an ongoing professional relationship with the client and who has agreed to supervise the client’s treatment including follow-up care;
An on-call or cross-coverage arrangement exists with the client’s regular treating healthcare provider or another healthcare provider who has established a professional relationship with the client;
A relationship exists in other circumstances as defined by the Arkansas State Medical Board (ASMB) or a licensing or certification board for other healthcare providers under the jurisdiction of the appropriate board if the rules are no less restrictive than the rules of the ASMB.
- A professional relationship is established if the provider performs a face to face examination using real time audio and visual telemedicine technology that provides information at least equal to such information as would have been obtained by an in-person examination. (See ASMB Regulation 2.8);
- If the establishment of a professional relationship is permitted via telemedicine under the guidelines outlined in ASMB regulations, telemedicine may be used to establish the professional relationship only for situations in which the standard of care does not require an in-person encounter and only under the safeguards established by the healthcare professional’s licensing board (See ASMB Regulation 38 for these safeguards including the standards of care); or
The healthcare professional who is licensed in Arkansas has access to a client’s personal health record maintained by a healthcare professional and uses any technology deemed appropriate by the healthcare professional, including the telephone, with a client located in Arkansas to diagnose, treat, and if clinically appropriate, prescribe a noncontrolled drug to the client.

See Miscellaneous section for additional restrictions.

SOURCE: AR Medicaid Provider Manual. Section I General Policy. Rule 105.190. Updated Jan. 1, 2022 (Accessed May 2024).

Medication Assisted Treatment (MAT) for Opioid Use Disorder

The provider at the distance site shall use both the GT modifier and the X2 or X4 modifier on the service claim.

SOURCE: AR Medicaid Provider Manual Physician Section II-129, 2/1/24, (Accessed May 2024)

Providers are encouraged to use telemedicine services when in-person treatment is not readily accessible.

SOURCE: AR Admin. Rule 230.000 (Lexis Nexis: 016-06 CARR 036) p. 12 (9/1/2020) (Accessed May 2024).

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

The provision of virtual care can include an interdisciplinary care team or be provided by individual clinical service provider.

SOURCE: PASSE Program, p. II-8 (1/1/23). (Accessed May 2024).

The Arkansas Medicaid Program shall reimburse for the following behavioral and mental health services provided via telemedicine:

Counseling and psychoeducation provided by a person licensed as:
- A psychologist;
- A psychological examiner;
- A professional counselor;
- An associate counselor;
- An associate marriage and family therapist;
- A marriage and family therapist;
- A clinical social worker; or
- A master social worker;
Crisis intervention services;
Substance abuse assessments;
Mental health diagnosis assessments for an individual under twenty-one (21) years of age; and
Group therapy for individuals who are eighteen (18) years of age or older under the current service definition determined by the Arkansas Medicaid Program and when provided via audio-visual technology that is compliant with the HIPPA and composed of beneficiaries of similar age and clinical presentation to qualified beneficiaries.

SOURCE: AR Code 20-77-141 (Accessed May 2024).

Ambulance Service

An ambulance service may:

Treat a beneficiary in alternative location if the ambulance service is coordinating the care of the beneficiary through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or
Triage or triage and transport a beneficiary to an alternative destination if the ambulance service is coordinating the care of the beneficiary through telemedicine with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.

An encounter between an ambulance service and a beneficiary that results in no transport of the enrollee is allowable if the beneficiary declines to be transported against medical advice and the ambulance service is coordinating the care of the beneficiary through telemedicine with a physician for a medical-based complaint.

An encounter between an ambulance service and a beneficiary is billable as follows:

The ambulance service may bill either a basic life support (BLS) or advanced life support (ALS) service according to the level of the service provided to the beneficiary, plus mileage. Mileage may be billed for treating in the alternative location (one-way mileage to the location of the beneficiary. Mileage rules set forth in Section 204.000, 205.000, 214.000, and 216.000 will otherwise be followed.

SOURCE: AR Medicaid Provider Manual. Section II Transportation. Rule 214.110, II-8. Updated 2/1/24, (Accessed May 2024).

ELIGIBLE SITES

Patient-Led Arkansas Shared Savings Entity (PASSE) Program

Virtual and telehealth services can be provided at the individual’s home or in a community setting.

SOURCE: PASSE Program, II-8 (1/1/23). (Accessed May 2024).

“Originating site” means a site at which a patient is located at the time healthcare services are provided to him or her by means of telemedicine, which includes the home of a patient.

SOURCE: AR Code 23-79-1601(4) (Accessed May 2024).

School Based

Regardless of whether the provider is compensated for healthcare services, if a healthcare provider seeks to provide telemedicine services to a minor in a school setting and the minor client is enrolled in Arkansas Medicaid, the healthcare provider shall:

Be the designated Primary Care Provider (PCP) for the minor client;
Have a cross-coverage arrangement with the designated PCP of the minor client; or
Have a referral from the designated PCP of the minor client.

If the minor client does not have a designated PCP, this section does not apply. Only the parent or legal guardian of the minor client may designate a PCP for a minor client.

SOURCE: AR Medicaid Provider Manual. Section I General Policy. Rule 105.190. Updated Jan. 1, 2022 (Accessed May 2024).

Early Intervention Day Treatment (EIDT)

Since EIDT services are clinic-based services, three services cannot be delivered through telemedicine or at any location other than through the licensed EIDT clinic. EIDT providers are considered all-inclusive, meaning a beneficiary attending an EIDT should have all of their habilitative occupational therapy, physical therapy, and speech-language pathology service needs performed by the EIDT program at the EIDT clinic.

SOURCE: AR Rules and Regulations, Sec. 016.05.24-002, (Accessed May 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Payment will include a reasonable facility fee to the originating site (the site at which the patient is located at the time telemedicine healthcare services are provided). In order to receive reimbursement, the originating site must be operated by a healthcare professional or licensed healthcare entity that is authorized to bill Medicaid directly for healthcare services.

There is no facility fee for the distant site. The professional or entity at the distant site must be an enrolled Arkansas Medicaid Provider. Any other originating sites are not eligible to bill a facility fee.

SOURCE: AR Medicaid Provider Manual. Section I General Policy. Rule 105.190. Updated Jan. 1, 2022. & Section III Billing Documentation. Rule 305.000. Updated Jan. 1, 2022, (Accessed May 2024).

The originating site shall submit a telemedicine claim under the billing providers “pay to” information, using HCPCS code Q3014. The code must be submitted for the same date of service as the professional code and must indicate the place of service (where the member was at the time of the telemedicine encounter). Except in the case of hospital facility claims, the provider who is responsible for the care of the member at the originating site shall be entered as the performing provider in the appropriate field of the claim. For outpatient claims that occur in a hospital setting, the provider must also use Place of Service code twenty-two (22) with the originating site billing Q3014. In the case of in-patient services, HCPCS code Q3014 is not separately reimbursable because it is included in the hospital per diem.

SOURCE: AR Medicaid Provider Manual. Section III Billing Documentation. Rule 305.000. III-8 to 9, Updated Jan. 1, 2022 (Accessed May 2024).

Federally Qualified Health Centers

Use procedure code and type of service code Y (paper claims only) to indicate telemedicine charges.

The charge associated with this procedure code should be an amount attributable to the telemedicine service, such as line (or wireless) charges. Medicaid will deny the charge and capture it in the same manner as with ancillary charges.

SOURCE: AR Medicaid Provider Manual. Section II FQHC. Rule 262.120. Updated 2/1/24. pg. II-34, (Accessed May 2024).

A health benefit plan shall provide a reasonable facility fee to an originating site operated by a healthcare professional or a licensed healthcare entity if the healthcare professional or licensed healthcare entity is authorized to bill the health benefit plan directly for healthcare services.

SOURCE: AR Code 23-79-1602(d) (1). (Accessed May 2024).

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California

Last updated 06/29/2024

POLICY

Synchronous Interaction

“Synchronous interaction” means a real-time interaction between …

POLICY

Synchronous Interaction

“Synchronous interaction” means a real-time interaction between a patient and a health care provider located at a distant site.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Jun. 2024).

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality, as outlined in this section, only if all of the following are satisfied:

The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual;
The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

For services or benefits provided via synchronous, interactive audio and visual telecommunications systems, the health care provider bills with modifier 95.
For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.
For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 8. (Accessed Jun. 2024).

CA Medicaid and Medi-Cal managed care plans are required to reimburse health care providers of applicable health care services delivered via video synchronous interaction, synchronous audio-only modality, or asynchronous store and forward, as applicable, at payment amounts that are not less than the amounts the provider would receive if the services were delivered via in-person, face-to-face contact, so long as the services or settings meet the applicable standard of care and meet the requirements of the service code being billed.

In-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by the department, when provided by video synchronous interaction, asynchronous store and forward, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed.

Applicable health care services appropriately provided through video synchronous interaction, asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities are subject to billing, reimbursement, and utilization management policies imposed by the department. Utilization management protocols adopted by the department pursuant to this section shall be consistent with, and no more restrictive than, those authorized for health care service plans pursuant to Section 1374.13 of the Health and Safety Code.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a provider furnishing services through video synchronous interaction or audio-only synchronous interaction shall also maintain and follow protocols to do one of the following:

Offer those services via in-person, face-to-face contact.
Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care. (This clause does not require a provider to schedule an appointment with a different provider on behalf of a patient.)

In implementing this subdivision, the department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services.

SOURCE: Welfare and Institutions Code 14132.725. (Accessed Jun. 2024).

In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.

SOURCE: Sec. 14132.72 of the Welfare and Institutions Code. (Accessed Jun. 2024).

Providers may establish a relationship with new patients via synchronous video telehealth visits.

SOURCE: Welfare and Institutions Code 14132.725; CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 3. (Accessed Jun. 2024).

Patient Choice of Telehealth Modality

Medi-Cal providers can offer a variety of telehealth modalities for covered Medi-Cal services to the extent that the service can be appropriately rendered via the allowable telehealth modalities. For Medi-Cal providers who do offer telehealth modalities, they are required to offer Medi-Cal recipients the ability to choose whether they want to receive covered Medi-Cal services via:

Synchronous, interactive audio/visual telecommunication systems (for example, video) or
Synchronous, telephone or other interactive audio-only telecommunications systems.

While Medi-Cal providers are required to offer both video and telephone telehealth modalities, Medi-Cal recipients may freely choose, and change at any time, their desired telehealth modalities, which includes the ability to decline video modalities and select audio-only (telephone) modalities if preferred and/or necessary given the recipient’s needs. For example, if the visit is related to sensitive services as defined in subsection (s) of Section 56.05 of the Civil Code, then the Medi-Cal recipient may prefer to utilize an audio-only (telephone) modality. Medi-Cal recipients shall be given the choice of how they receive their covered Medi-Cal services.

Exception to Telehealth Modalities Provider Requirement

Since broadband is necessary to ensure quality and effective communication between Medi-Cal providers and recipients, Medi-Cal providers are exempt from the requirement to offer both telehealth modalities if the Medi-Cal provider does not have access to broadband. Note: Broadband refers to high-speed internet access that is always on and faster than traditional dial-up access. Broadband includes several high-speed transmission technologies, such as fiber, wireless, satellite, digital subscriber line, and cable. For the purposes of delivering telehealth services to patients, DHCS uses the Federal Communications Commission’s (FCC) definition of broadband and the FCC minimum mbps upload/download speeds. Medi-Cal providers claiming this exception must maintain appropriate supporting documentation, which should be made available to DHCS upon request. For example, supporting documentation might include confirmation from an internet services provider regarding the lack of broadband service in a particular coverage area.

Right to In-person Services

Medi-Cal providers furnishing services to Medi-Cal recipients through telehealth modalities must also either offer services in-person or have a documented process in place to link Medi-Cal recipients to in-person care within a reasonable time if in-person services are unavailable from the provider.

If the Medi-Cal provider chooses to link the Medi-Cal recipient to in-person care to satisfy this requirement, then they must provide a referral to and facilitation of in-person care that does not require a recipient to independently contact a different Medi-Cal provider to arrange for such care. The Medi-Cal provider may initiate a process by which a different Medi-Cal provider in their office or an affiliated in-person care site contacts the Medi-Cal recipient directly to schedule an in-person visit.

The referring Medi-Cal provider or a member of their staff must confirm the referred Medi-Cal provider has at least attempted to contact the recipient to schedule an in-person appointment. However, the Medi-Cal referring provider is not required to schedule an appointment with a different provider on behalf of the Medi-Cal recipient. The Medi-Cal provider must offer referral and facilitation support that is minimally burdensome to the Medi-Cal recipient. Medi-Cal providers must maintain documentation of their process to link Medi-Cal recipients to in-person care, which should be made available to DHCS upon request.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 6-7; Medi-Cal: Family PACT – Benefits: Clinical Services Overview (May 2024), p. 10. (Accessed Jun. 2024).

Brief Virtual Communications and Check-ins

Virtual or telephonic communication includes a brief communication with an established patient not physically present (face-to-face). Medi-Cal providers may be reimbursed using HCPCS codes G2010 and G2012 for brief virtual communications.

HCPCS code G2012: Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5 to 10 minutes of medical discussion. G2012 can be billed when the virtual communication via a telephone call.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 12. (Accessed Jun. 2024).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Services rendered via telehealth must be FQHC or RHC covered services. Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site. Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from the FQHC pursuant to the federal Health Resources Services Administration requirements. A patient may be “established” via synchronous interaction if all of the conditions of the “New Patient” requirements in this manual section are met.

See manual for billing examples.

In regard to patient choice of telehealth modality and right to in-person services requirements, FQHC/RHC providers are directed to refer to the policies found in more detail in the Telehealth Manual.

SOURCE: CA Dept. of Health Care Services, Part 2 Manual, Medi-Cal Rural Health Clinics and Federally Qualified Health Centers (Mar. 2024), p. 12-13, 15-16. (Accessed Jun. 2024).

Visits shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction.

Effective on a date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:

Offer those services via in-person, face-to-face contact.
Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.

SOURCE: Welfare and Institutions Code 14132.100. (Accessed Jun. 2024).

Family PACT

Family PACT providers must ensure that the covered Family PACT service or benefit being delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code(s) associated with the Family PACT covered service or benefit, as well as any other requirements described in this manual. In addition, Family PACT services rendered by the use of a telehealth modality must follow ICD-10-CM diagnosis code billing policy as noted in this manual. All healthcare practitioners rendering Family PACT covered benefits or services under this policy must comply with all applicable state and federal laws.

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. May. 2024, Pg. 7. (Accessed Jun. 2024).

A Family PACT provider may enroll and recertify clients through synchronous video or audio-only synchronous telehealth modalities. See manual for more information.

SOURCE: CA Department of Health Care Services. Family PACT Client Eligibility Manual. Apr. 2023. Pg. 1. (Accessed Jun. 2024).

Managed Care

To ensure proper payment and record of Covered Services provided via Telehealth, all Providers must use the modifiers defined in the Medi-Cal Provider Manual with the appropriate CPT-4 or HCPCS codes when coding for services delivered through both synchronous interactions and asynchronous store and forward telecommunications. Regarding the rate of reimbursement, unless otherwise agreed to by the MCP and Provider, MCPs must reimburse Network Providers at the same rate, whether a Covered Service is provided in-person or through Telehealth, if the service is the same regardless of the modality of delivery, as determined by the Provider’s description of the service on the claim.

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 23-007: Telehealth Services Policy. Apr. 10, 2023. (Accessed Jun. 2024).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Services rendered via telehealth must be IHS-MOA covered services.

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

IHS-MOA clinics must submit claims for telehealth services using the appropriate per visit IHS-MOA billing codes, modifiers and related claims submission requirements. Providers may refer to the Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics: Billing Codes section in the appropriate Part 2 manual.
IHS-MOA clinics are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the IHS-MOA rate.

See manual for billing examples.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8. (Accessed Jun. 2024).

Local Educational Agency (LEA)

For dates of service on or after May 12, 2023, LEAs may bill for covered direct medical services under the LEA Medi-Cal Billing Option Program according to the following guidelines. All LEA services covered under the LEA Medi-Cal Billing Option Program may be billed by participating LEAs when performed via telehealth, except for services that preclude a telehealth modality, such as specialized medical transportation services. Services delivered via telehealth must meet the requirements described in the Medi-Cal provider manual.

Practitioners must use the “LEA Services Billing Codes Chart” in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates provider manual section to find LEA services that are reimbursable when rendered by telehealth. The first column of the chart indicates “Add modifier 95 if via telehealth” when the telehealth service is reimbursable under the LEA Medi-Cal Billing Option Program.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Jun. 2023. Pg. 1, 5. (Accessed Jun. 2024).

Effective retroactively for dates of service on or after July 1, 2023, CPT^® codes 99402, 99403 and 99404 (preventive medicine counseling and/or risk factor reduction intervention) have been added for Provider Type 55 to allow for additional minutes of service for Health Education and Anticipatory Guidance Individualized Education Plan (IEP)/Individualized Family Services Plan (IFSP) under the Local Educational Agency (LEA) Medi-Cal Billing Option Program (BOP). The chart notes that the codes are eligible via telehealth when billed with the addition of modifier 95.

SOURCE: CA Department of Health Care Services. (DHCS). Addition of CPT Codes for LEA BOP. Apr. 2024. (Accessed Jun. 2024).

Dental Services

The Department of Health Care Services has opted to permit the use of teledentistry (including live video) as an alternative modality for the provision of select dental services.

A patient who receives teledentistry services under these provisions shall also have the ability to receive in-person services from the dentist or dental practice or assistance in arranging a referral for in-person services.

SOURCE: CA Department of Health Care Services (DHCS). Dental Provider Handbook. (2024) Pg. 4-22 – 4-24. (Accessed Jun. 2024).

Drug Medi-Cal Treatment Program

A county that enters into a Drug Medi-Cal Treatment Program contract with the department shall reimburse Drug Medi-Cal certified providers for medically necessary Drug Medi-Cal reimbursable services, as defined in Section 14124.24, provided by a licensed practitioner of the healing arts, or a registered or certified alcohol or other drug counselor or other individual authorized by the department to provide Drug Medi-Cal reimbursable services when those services meet the standard of care, meet the requirements of the service code being billed, and are delivered through video synchronous interaction or audio-only synchronous interaction.

SOURCE: Welfare and Institutions Code 14132.731. (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association, associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual; and
The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

For services or benefits provided via synchronous, interactive audio and visual telecommunications systems, the health care provider bills with modifier 95.
For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.
For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

Certain types of benefits or services that would not be expected to be appropriately delivered via telehealth include, but are not limited to, benefits or services that are performed in an operating room or while the patient is under anesthesia, require direct visualization or instrumentation of bodily structures, involve sampling of tissue or insertion/removal of medical devices and/or otherwise require the in-person presence of the patient for any reason.

The amount paid by DHCS and Medi-Cal managed care plans for a service rendered via telehealth is the same as the amount paid for the applicable service when rendered in-person.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 4, 8. (Accessed Jun. 2024).

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Jun. 2024).

Evaluation and management services may be delivered via telehealth when Medi-Cal requirements are met.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 27. Dec 2022. (Accessed Jun. 2024).

Modifier 95 must be used for Medi-Cal covered benefits or services delivered via synchronous, interactive audio/visual, telecommunications systems. Only the portion(s) of the telehealth service rendered at the distant site are billed with modifier 95. The use of modifier 95 does not alter reimbursement for the CPT or HCPCS code.

See manual for telecommunications system requirements.

See Telehealth Modifier Reference Sheet- Organized by Delivery System and 2024 Medi-Cal Provider Training: RHC/FQHC Services, p. 16 for more information on modifiers.

Evaluation and Management (E&M) and all other covered Medi-Cal services provided at the originating site (in-person with the patient) during a telehealth transmission are billed according to standard Medi-Cal policies (without modifier 95). The E&M service must be in real-time or near real-time (delay in seconds or minutes) to qualify as an interactive two-way transfer of medical data and information between the patient and health care provider.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 10. (Accessed Jun. 2024).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site.

Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Mar. 2024. Pg. 16. (Accessed Jun. 2024).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)/Tribal FQHCs

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

Tribal FQHCs may bill for a telehealth visit if it is medically necessary for a billable provider to be present with a patient during the telehealth visit.
IHS-MOA clinics/tribal FQHCs must submit claims for telehealth services using the appropriate per visit IHS-MOA billing codes/tribal FQHC all-inclusive billing code sets, modifiers and related claims submission requirements. Providers may refer to the Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics: Billing Codes section in the appropriate Part 2 manual. Tribal FQHC providers may refer to the Tribal Federally Qualified Health Centers (Tribal FQHCs): Billing Codes section in the appropriate Part 2 manual.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jun. 2024, Pg. 7-8; Tribal FQHC May 2023, p. 13. (Accessed Jun. 2024).

Dental Services

Synchronous interaction, or live transmission, is a real-time interaction between a member and a provider located at a distant site. Live transmissions are limited to 90 minutes per member per provider, per day. Please note, live transmissions may be provided at the member’s request or if the health care provider believes the service is clinically appropriate. All dental information transmitted during the delivery of Medi-Cal covered benefits or services via a telehealth modality must become part of the patient’s dental record maintained by the Medi-Cal provider at the distant site.

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. 2024. Pg. 4-24. (Accessed Jun. 2024).

Home Health & Durable Medical Equipment

Telehealth may be used to deliver a face-to-face encounter related to the primary reason a recipient requires home health services or a durable medical equipment item.

SOURCE: Department of Health Care Services. Home Health Agencies (HHA) Provider Handbook. (Feb. 2021), Pg. 3. & Department of Health Care Services. Durable Medical Equipment (DME): An Overview. (July 2021), Pg. 6. (Accessed Jun. 2024).

CA Children’s Services (CCS)

CA Children’s Services Program lists eligible CPT/HCPCS codes in Numbered Letters 16-1217 & 09-0718. Codes specifically include tele-speech, tele-auditory verbal therapy, tele-auditory habilitation and tele-auditory rehabilitation services in the home, with the parent or guardian working with the speech therapist at the distant site.

SOURCE: Number Letter 09-0718 to CA Children’s Services Program. Jul. 10, 2018. (Accessed Jun. 2024).

CCS providers must request prior authorization services from CCS paneled physicians (22, CCR Section 41412) who are available to provide telehealth services. Prior authorization requests are also authorized to CCS-approved hospitals and outpatient special care centers. GHPP providers must be Medi-Cal enrolled providers.

Physical and Occupational Therapy may be offered through appropriate telehealth modalities. Medical Therapy Unit therapists may offer remote/virtual teletherapy services as an alternative to in-person visits, as appropriate and directed by the Medical Therapy Conference and directing physicians. CCS clients receiving services through a Special Care Center and/or Medical Therapy Program Medical Therapy Conference must have an annual in-person evaluation by a CCS-paneled physician. GHPP clients require an annual evaluation to ensure continued program coverage.

Billing for telehealth services is contingent upon the CCS Program or GHPP clients meeting all eligibility criteria, with an approved CCS Program/GHPP SAR, and in conformance with required Medi-Cal claims submission procedures as outlined in the DHCS Medi-Cal Telehealth Policy.

When submitting a SAR for synchronous telemedicine services, the provider must use codes provided in the American Medical Association (AMA’s) CPT Manual, Appendix P.
Telehealth modifiers (93, 95 or GQ) are required on SARs to differentiate the telehealth service from the equivalent in-person service.
For services or benefits provided via synchronous, interactive audio, and telecommunications systems, the health care provider bills with modifier 95.
For services or benefits provided via synchronous, telephone or other interactive audio-only telecommunications systems, the health care provider bills with modifier 93.
For services or benefits provided via asynchronous store-and-forward telecommunications systems, the health care provider bills with modifier GQ.

For Whole Child Model (WCM) counties, the client’s managed care plan (MCP) shall be responsible for authorizing, coordinating, and covering CCS telehealth services.

SOURCE: Department of Health Care Services. Numbered letter 03-0723 to the Children’s Services Program and Genetically Handicapped Persons Program (GHPP). Jul. 7, 2023 – supersedes Department of Health Care Services. Numbered letter 16-1217 to the CA Children’s Services Program and Genetically Handicapped Persons Program (GHPP). Dec. 22, 2017. (Accessed Jun. 2024).

Opioid Use Disorder Treatment Services

Outpatient treatment services for opioid use disorder (OUD), which include management, care coordination, psychotherapy and counseling are reimbursable using HCPCS codes G2086, G2087 and G2088. At least one psychotherapy service must be furnished in order to bill for HCPCS codes G2086 thru G2088. Although the descriptions for these codes refer to “office-based treatment,” these services may be delivered via telehealth when they meet Medi-Cal requirements. See Medi-Cal Telehealth Provider Manual.

HCPCS codes G2086 thru G2088 are not reimbursable for treatment in state-licensed Opioid Treatment Programs as defined in Health and Safety Code Section 11875. HCPCS codes G2086 and G2087 each have a frequency limit of once per calendar month, per recipient, any provider and G2088 has a frequency limit of two per calendar month, per recipient, any provider. Only one provider can be reimbursed for HCPCS code G2086, G2087 or G2088 per calendar month.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 47-48. Dec. 2022. (Accessed Jun. 2024).

The Program for All Inclusive Care for the Elderly (PACE)

A PACE organization approved by the department pursuant to Chapter 8.75 (commencing with Section 14591) may use video telehealth to conduct initial assessments and annual re-assessments for eligibility for enrollment in the PACE program.

SOURCE: Welfare and Institutions Code 14132.725. (Accessed Jun. 2024).

Multipurpose Senior Services Program

Providers are required to report revenue code 0780 with each MSSP procedure code that is rendered via telehealth.

SOURCE: DHCS Provider Bulletin, Multipurpose Senior Services Program Transitions to HIPAA-Compliant Code Sets. Dec. 2023. & Multipurpose Senior Services Program (MSSP) Billing Codes, p. 15. Dec. 2023. (Accessed Jun. 2024).

Doula, Community Health Worker (CHW) and Asthma Preventive Services

Doulas may provide services described in the Doula Services manual via telehealth.

Community Health Workers (CHWs) may provide services described in the Community Health Worker (CHW) Preventive Services manual via telehealth

Asthma preventive education and training services described in the Asthma Preventive Services (APS) manual may be provided via telehealth by unlicensed asthma preventive service providers. In-home environmental trigger assessments for asthma may not be conducted via telehealth and must be conducted in-person.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan 2023). Pg. 4. (Accessed Jun. 2024).

Doula Services

IHS-MOA and Tribal FQHC providers may bill for doula services provided via telehealth using either modifier 93 for synchronous audio-only or modifier 95 for synchronous video.

SOURCE: CA Dept. of Health Care Services (DHCS) Provider Bulletin, Doula Services Now a Benefit for IHS-MOA and Tribal FQHC Providers. Jul. 2023. (Accessed Jun. 2024).

Doulas may bill for services provided by telehealth using either modifier 93 for synchronous audio-only or modifier 95 for synchronous video. Doulas should refer to the Medicine: Telehealth section in Part 2 of the Provider Manual for guidance regarding providing services via telehealth for prenatal or postpartum visits, labor and delivery support, and for abortion and miscarriage support.

SOURCE: CA Dept. of Health Care Services (DHCS) Doula Services Manual, p. 5-6. (Dec. 2022). (Accessed Jun. 2024).

Family PACT

Family PACT covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Family PACT coverage and reimbursement policies, including any Treatment Authorization Request (TAR) requirements, may be provided via a telehealth modality, as outlined in this section, only if all of the following are satisfied:

The provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth.
The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the Family PACT covered service or benefit, as well as any extended guidelines as described in this section and the Medicine: Telehealth section in the appropriate Part 2 Medi-Cal manual.
The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a client’s right to his or her medical information.

The amount paid by DHCS and Medi-Cal managed care plans for a service rendered via telehealth is the same as the amount paid for the applicable service when rendered in-person.

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. May. 2024, Pg. 11. (Accessed Jun. 2024).

Medication Abortion

The COVID-19 PHE ended May 11, 2023, but DHCS will continue to allow flexibilities granted during the PHE for services billed under HCPCS code S0199. The following policies are effective July 1, 2023:

Medication abortion policy allows for 77 days gestational age and continues the COVID-19 PHE policies regarding in-person visits and ultrasounds without payment reduction.
When determined clinically appropriate based on a provider’s clinical judgement, services may be provided through telehealth. Confirmation of pregnancy must be documented.
Ultrasound to confirm gestational age and/or intrauterine pregnancy, and ultrasound to confirm completion of abortion, must be provided when clinically indicated, but is not required in all cases.
Providers may bill S0199 without providing a pre-abortion ultrasound when a pre-abortion ultrasound is not clinically indicated.
Providers may bill S0199 without providing a post-abortion ultrasound when a post-abortion ultrasound is not clinically indicated.
Providers may bill S0199 when a post-abortion assessment is provided via telehealth, if clinically appropriate and if patient prefers assessment via telehealth. An in-person visit must be offered but is not required to bill S0199.
For recipients who do not show up for follow-up visits, HCPCS code S0199 must be billed using the “from-through” method with the “no show” date as the “through” date and modifier 52 is not required.

In addition, as specified in DHCS telehealth guidance, services may be provided via telehealth when:

The treating health care practitioner at the distant site believes that the Medi-Cal benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth, subject to oral or written consent by the member.
The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual.
The benefits or services provided via telehealth satisfies all laws regarding confidentiality of health care information and a patient’s right to their medical information.

As specified in the above telehealth guidance, delivery of benefits or services that require the in-person presence of the patient for any reason are not appropriate for delivery via a telehealth modality.

SOURCE: DHCS Provider Bulletin, Post-PHE Policy Clarification for Medication Abortion. (Sept. 2023). (Accessed Jun. 2024).

Managed Care

Existing Covered Services, identified by Current Procedural Terminology – 4th Revision (CPT-4) or Healthcare Common Procedure Coding System (HCPCS) codes and subject to any existing treatment authorization requirements, may be provided via a Telehealth modality only if all of the following criteria are satisfied:

The treating Provider at the distant site believes the Covered Services being provided are clinically appropriate to be delivered via Telehealth based upon evidence-based medicine and/or best clinical judgment.
The Member has provided verbal or written consent.
The Medical Record documentation substantiates that the Covered Services delivered via Telehealth meet the procedural definition and components of the CPT-4 or HCPCS code(s) associated with the Covered Service. Providers are not required to:
- Document a barrier to an in-person visit for Covered Services provided via Telehealth (WIC section 14132.72(d)); or
- Document the cost effectiveness of Telehealth to be reimbursed for Covered Services provided via a Telehealth modality.
The Covered Services provided via Telehealth meet all state and federal laws regarding confidentiality of health care information and a Member’s right to their own medical information.

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 23-007: Telehealth Services Policy. Apr. 10, 2023. (Accessed Jun. 2024).

Behavioral Health Services

Medi-Cal covered services delivered via telehealth (synchronous audio-only and synchronous video interactions) are reimbursable in Medi-Cal Specialty Mental Health Services (SMHS), the Drug Medi-Cal Organized Delivery System (DMC-ODS), and the Drug Medi-Cal (DMC) programs (including initial assessments, only as set forth in this BHIN). Patient choice must be preserved; therefore, patients have the right to request and receive in-person services. See Behavioral Health Information Notice No.: 23-018 for program specific telehealth reimbursement requirements. Behavioral Health Information Notice No.: 21-075 has additional program specific information related to telehealth services.

The use of telehealth modifiers on SMHS, DMC, and DMC-ODS claims is mandatory and necessary for accurate tracking of telehealth usage in behavioral health. Billing codes must be consistent with the level of care provided. The following codes shall be used in SMHS, DMC, and DMC-ODS:

Synchronous video interaction service: GT
Synchronous audio-only interaction service: SC
Asynchronous store and forward (e-consult in DMC-ODS only): GQ

Effective July 1, 2023, additional modifiers will be required for Current Procedural Terminology (CPT) codes after DHCS implements a successor payment methodology and transitions from Healthcare Common Procedure Coding System (HCPCS) codes to a combination of HCPCS and CPT codes. See BHIN 22-046 for more information and the MEDCCC Library for the version of the billing manuals that will take effect in 2023. If a telehealth modifier is used for outpatient services on or after July 1, 2023, the place of service must be “02” or “10” unless the service is Mobile Crisis Services.

SOURCE: CA Department of Health Care Service (DHCS). Behavioral Health Information Notice No.: 23-018. Apr. 25, 2023. Pg. 2, 8. (Accessed Jun. 2024).

Managed Care & Behavioral Health

Effective no sooner than January 1, 2024, to preserve a beneficiary’s right to access covered services in person, a provider furnishing services through telehealth must do one of the following:

Offer those same services via in-person, face-to-face contact; or
Arrange for a referral to, and a facilitation of, in-person care that does not require a beneficiary to independently contact a different provider to arrange for that care.

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 23-007: Telehealth Services Policy. Apr. 10, 2023, p. 3.; CA Department of Health Care Service (DHCS). Behavioral Health Information Notice No.: 23-018. Apr. 25, 2023. Pg. 3-5, 8 (Accessed Jun. 2024).

Diabetes Prevention Program (DPP)

The Medi-Cal DPP can be offered through telehealth where trained peer coaches deliver sessions via remote classroom or telehealth where the peer coach is present in one location and participants are calling or video-conferencing in from another location. DPP providers that offer online, virtual, or distance learning programs may bill one of the fourteen HCPCS codes in conjunction with an appropriate telehealth modifier when all requirements for billing the HCPCS code have been met.

SOURCE: CA Dept. of Health Care Services. Medi-Cal’s Diabetes Prevention Program (DPP) Policy Preview. Pg. 3, 8. (Accessed Jun. 2024).

Medication Therapy Management

MTM pharmacist services can be rendered via telecommunication systems provided the pharmacy is meeting the contractual requirements for telehealth. When MTM services are provided or received, through a telecommunication system, the provider must indicate on the claim by entering the most applicable Place of Service code in the Place of Service Code field (Box 24b).

SOURCE: CA Dept. of Health Care Services, Medi-Cal Manual: Medication Therapy Management, May 2024, p. 7. (Accessed Jun. 2024).

Non-Specialty Mental Health Services: Psychiatric and Psychological Services

NSMHS may be delivered via telehealth when Medi-Cal requirements are met. For more information, refer to the Medicine: Telehealth section of this manual.

SOURCE: CA Dept. of Health Services, Medi-Cal Non-Specialty Mental Health Services: Psychiatric and Psychological Services, Dec. 2021, p. 5. (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

The health care provider rendering Medi-Cal covered benefits or services provided via a telehealth modality must meet the requirements of Business and Professions Code (B&P Code), Section 2290.5(a)(3), or must be otherwise designated by the Department of Health Care Services (DHCS) pursuant to Welfare and Institutions Code (WIC) 14132.725 (b)(2)(A).

A licensed health care provider rendering Medi-Cal covered benefits or services via a telehealth modality must be licensed in California, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group.

The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

For purposes of telehealth [the distant site] can be different from the administrative location.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 2-3. (Accessed Jun. 2024).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Billable providers are eligible to deliver covered FQHC/RHC services. Providers may refer to “RHC/FQHC Covered Services” in this manual section.

Telehealth services must meet all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter with a billable provider and meet the applicable standard of care. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to Health Resources Services Administration requirements.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Mar. 2024. Pg. 12. ( (Accessed Jun. 2024).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Billable providers are eligible to deliver available services offered under IHS-MOA services.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jun. 2024. Pg. 7-8. (Accessed Jun. 2024).

Dental Professionals

For Medi-Cal dental benefits or services, Medi-Cal enrolled dentists and allied dental professionals (under the supervision of a dentist) may render limited services via synchronous/live transmission teledentistry, so long as such services are within their scope of practice, when billed using CDT code D9995 for dates of service on or after May 16, 2020.

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. 2024. Pg. 4-24-26. (Accessed Jun. 2024).

Psychiatrists

Psychiatrists may bill for services delivered through telehealth in accordance with the Medicaid state plan.

SOURCE: Sec. 14132.73 of the Welfare and Institutions Code. (Accessed Jun. 2024).

Doula, Community Health Worker (CHW) and Asthma Preventive Services

Doulas may provide services described in the Doula Services manual via telehealth.

Community Health Workers (CHWs) may provide services described in the Community Health Worker (CHW) Preventive Services manual via telehealth

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 4. (Accessed Jun. 2024).

Non-Physician Medical Practitioners

Licensed Midwife Code – T1014 Telehealth.

SOURCE: CA Dept. of Health Care Services, Medi-Cal, Non-Physician Medical Practitioners, Mar. 2024, p. 27. (Accessed Jun. 2024).

ELIGIBLE SITES

“Originating site” means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates. For purposes of reimbursement for covered treatment or services provided through telehealth, the type of setting where services are provided for the patient or by the health care provider is not limited (Welfare and Institutions Code [WIC] Section 14132.72(e)). This may include, but is not limited to, a hospital, medical office, community clinic, or the patient’s home.

“Distant site” means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system. The distant site for purposes of telehealth can be different from the administrative location.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Jun. 2024).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

The billable provider, employed or under direct contract with an FQHC or RHC can respond from any location, including their home, during a time that they are scheduled to work for the FQHC or RHC.

For the purposes of payment for covered treatment or services provided through telehealth, the department shall not limit the type of setting where services are provided for the patient or by the health care provider.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Mar. 2024. Pg. 17. (Accessed Jun. 2024).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refers to fee-for-service policy for the definition of an ‘originating site’ and ‘distant site’.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jun. 2024. Pg. 7. (Accessed Jun. 2024).

Family PACT

“Distant site” means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system. The distant site can be different from the enrolled Family PACT service site for telehealth purposes only.

“Originating site” means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates. For purposes of reimbursement for Family PACT covered services provided through telehealth, the type of setting where services are provided for the client or by the health care provider is not limited. The type of setting may include, but is not limited to, an enrolled Family PACT site such as a FQHC, medical office, community clinic, or the client’s home.

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. May. 2024, Pg. 8. (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

No Reference Found.

FACILITY/TRANSMISSION FEE

The originating site facility fee is reimbursable only to the originating site when billed with HCPCS code Q3014 (telehealth originating site facility fee). Transmission costs incurred from providing telehealth services via audio/video communication is reimbursable when billed with HCPCS code T1014 (telehealth transmission, per minute, professional services bill separately).

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 13. (Accessed Jun. 2024).

FQHC & RHC/IHS-MOA

FQHCs/RHCs/IHS-MOA are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the PPS/AIR/IHS-MOA rates, as applicable.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Mar. 2024. Pg. 13; CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8. (Accessed Jun. 2024).

Local Education Agency

Ancillary costs, such as equipment, technical support, facility fee, and transmission charges incurred while providing telehealth services via audio/video communication are not reimbursable.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Jun. 2023. Pg. 5 (Accessed Jun. 2024).

Every Woman Counts Program

Effective retroactively for dates of service on or after November 1, 2013, HCPCS codes Q3014 (telehealth originating site facility fee) and T1014 (telehealth transmission, per minute, professional services bill separately) are benefits of the Every Woman Counts (EWC) program.

SOURCE: Department of Health Care Services. Every Woman Counts Program Manual. Pgs. 42-43. Apr. 2024. (Accessed Jun. 2024).

Rates: Maximum Reimbursement for Optometry Services

T1014 – Telehealth transmission, per minute, profesional services bill separately.

SOURCE: Dept of Health Care Services, Medi-Cal, Rates: Maximum Reimbursement for Optometry Services, Oct. 2021, p. 6. (Accessed Jun. 2024).

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Colorado

Last updated 08/13/2024

POLICY

CO Medicaid will cover medically necessary medical and surgical …

POLICY

CO Medicaid will cover medically necessary medical and surgical services furnished to eligible members.

Telemedicine services may be provided under two arrangements.

The first arrangement is when a member receives services via a live audio/visual connection from a single provider. This is the predominant arrangement for telemedicine.
The second arrangement is when a member and a provider are physically in the same location and additional services are provided by a second (distant) provider via a live audio/visual connection. In this arrangement the provider who is present with the member is called the “originating provider”, and the provider located at a different site, acting as a consultant, is called the “distant provider”.

The member must be present during any Telemedicine visit.

It is acceptable to use Telemedicine to facilitate live contact directly between a member and a provider.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual,” 5/24. (Accessed Aug. 2024).

In-person contact between a health care or mental health care provider and a patient is not required under the state’s medical assistance program for health care or mental health care services delivered through telemedicine that are otherwise eligible for reimbursement under the program. Any health care or mental health care service delivered through telemedicine must meet the same standard of care as an in-person visit. Telemedicine may be provided through interactive audio, interactive video, or interactive data communication, including but not limited to telephone, relay calls, interactive audiovisual modalities, and live chat as long as the technologies are compliant with HIPAA. The health care or mental health care services are subject to reimbursement policies developed pursuant to the medical assistance program. This section also applies to managed care organizations that contract with the state department pursuant to the statewide managed care system only to the extent that:

Health care or mental health care services delivered through telemedicine are covered by and reimbursed under the Medicaid per diem payment program; and
Managed care contracts with managed care organizations are amended to add coverage of health care or mental health care services delivered through telemedicine and any appropriate per diem rate adjustments are incorporated.

The reimbursement rate for a telemedicine service shall, as a minimum, be set at the same rate as the medical assistance program rate for a comparable in-person service. The state department may consider setting the reimbursement rate on a monthly basis as well as on a daily or per-visit basis.

SOURCE: CO Revised Statutes 25.5-5-320. (Accessed Aug. 2024).

Interim Therapeutic Restorations

In-person contact between a health care provider and a member is not required under the state’s medical assistance program for the diagnosis, development of a treatment plan, instruction to perform an interim therapeutic restoration procedure, or supervision of a dental hygienist performing an interim therapeutic restoration procedure. A health care provider may provide these services through telehealth, including store-and-forward transfer, and is entitled to reimbursement for the delivery of those services via telehealth to the extent the services are otherwise eligible for reimbursement under the program when provided in person. The services are subject to the reimbursement policies developed pursuant to the state medical assistance program.

SOURCE: CO Revised Statutes 25.5-5-321.5 as proposed to be amended by SB 24-176 (2024 Session). (Accessed Aug. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Colorado Medicaid will reimburse for medical and mental health services delivered through telemedicine that are otherwise eligible for reimbursement under the program.

Health care or mental health care services includes speech therapy, physical therapy, occupational therapy, hospice care, home health care, substance use disorder treatment, and pediatric behavioral health care.

SOURCE: CO Revised Statutes 25.5-5-320 as proposed to be amended by HB 24-1045 (2024 Session). (Accessed Aug. 2024).

Services may be rendered via telemedicine when the service is:

A covered Health First Colorado benefit,
Within the scope and training of an enrolled provider’s license, and
Appropriate to be rendered via telemedicine.

All services provided through telemedicine shall meet the same standard of care as in-person care.

Refer to the Telemedicine Website for a list of billing codes which may be used with Place of Service (POS) 02 or 10.

The reimbursement rate for a telemedicine service shall, as a minimum, be set at the same rate as the medical assistance program rate for a comparable in-person service.

Providers may only bill procedure codes which they are already eligible to bill.

Place of Services codes 02 and 10 can be used during telehealth encounters:

POS 02: Telehealth provided other than in the patient’s home. The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
POS 10: Telehealth Provided in Patient’s Home. The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

Additionally, modifiers FQ, FR, 93, and 95 can be added to POS 2 and 10:

FQ: The service was furnished using audio-only communication technology.
FR: The supervising practitioner was present through two-way, audio/video communication technology.
93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine – Provider Information”, CO Department of Health Care Policy and Financing, CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual”, 5/24. (Accessed Aug. 2024).

Physician services may be provided as telemedicine in accordance with Section 8.095.

SOURCE: Colorado Adopted Rule 8.200.3.B. (Accessed Aug. 2024).

Any Health First Colorado-covered physician services that are within the scope of a provider’s practice and training and appropriate for telemedicine may be rendered via telemedicine.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine – Provider Information”. (Accessed Aug. 2024).

Procedure codes listed below under “Telemedicine Modifier GT” will receive an additional $5.00 to the fee listed on the most recent Health First Colorado Fee Schedule when billed using modifier GT.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

All Colorado Medicaid clients are eligible for medical and behavioral services delivered by telemedicine.

Covered Telemedicine services must:

Meet the same standard of care as in-person care;
Be compliant with state and federal regulations regarding care coordination;
Be services the Department has approved for delivery through Telemedicine;
Be within the provider’s scope of practice and for procedure codes the provider is already eligible to bill;
Be provided only where contact with the provider was initiated by the member for the services rendered; and
Be provided only after the member’s consent, either verbal or written, to receive telemedicine services is documented.

The reimbursement rate for a Telemedicine service shall, as a minimum, be set at the same rate as the Colorado Medicaid rate for a comparable in-person service.

SOURCE: Colorado Adopted Rule 8.095.2, 8.095.4, 8.095.7. (Accessed Aug. 2024).

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b – g.
The service provides a safe environment or situation for the child.
The service is not for the convenience of the caregiver.
The service is medically necessary.
The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
The service is the least costly.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Durable Medical Equipment Encounters

Face-to-face encounters for durable medical equipment, prosthetics, orthotics, and supplies may be performed via telehealth if available.

Telehealth visits are allowed for reauthorization of continuous glucose monitoring in some cases.

SOURCE: CO Department of Health Care Policy and Financing. “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies”, 7/24. (Accessed Aug. 2024).

Certain providers are authorized to order durable medical equipment and may conduct a related face-to-face encounter via telehealth or telemedicine if those services are covered by the Medical Assistance Program.

SOURCE: Colorado Adopted Rule 8.590.7.N. (Accessed Aug. 2024).

Pediatric Behavioral Therapy

Pediatric Behavioral Therapists are covered under the telemedicine policy.

SOURCE: CO Department of Health Care Policy and Financing. “Pediatric Behavioral Therapies Billing Manual”, 8/24 (Accessed Aug. 2024).

Pediatric Behavioral Therapy (PBT) providers will not be required to collect Electronic Visit Verification (EVV) data when the services are delivered via telehealth, effective May 1, 2023. EVV remains a requirement for all other PBT services when delivered in the home or community.

SOURCE: CO Dept. of Health Care Policy and Financing. Provider Bulletin. May 2023. (Accessed Aug. 2024).

Screening Brief Intervention Treatment

Screening Brief Intervention Treatment may be provided via telemedicine (simultaneous audio and video transmission or by telephone audio-only) with the member.

SOURCE: CO Department of Health Care Policy and Financing. “Screening, Brief Intervention and Referral to Treatment”, 3/23. (Accessed Aug. 2024).

Education-Only Services

Colorado Medicaid provides reimbursement for education-only services provided through telemedicine. This includes services such as Diabetes Self-Management Education and Support (DSMES) and tobacco cessation counseling.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B1900434. Aug. 2019. (Accessed Aug. 2024).

Education-only services was removed from the list of “Not Covered Services” section in the provider manual in June 2019.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Abortion Services

Certain medicinal abortion services may be provided by telemedicine. Physicians (MDs/DOs), Certified Nurse Midwives (CNMs), Advanced Practice Nurses (APNs) or Physician Assistants (PAs) who wish to prescribe Mifepristone must complete a Prescriber Agreement Form prior to ordering and dispensing Mifepristone. The medicinal abortion method (not available for use in maternal life-endangering situations) can be provided by these identified provider types and identified places of service effective May 21, 2021, when prescribed or dispensed and provided by eligible Mifepristone-prescribing practitioners.

HCPCS S0199 covers:

Office visit #1 or telemedicine counseling/communications
- Patient check-in or telemedicine services, all counseling and consultation
- Confirmation of pregnancy and fetal gestational age (either by hCG or ultrasound)
Follow-up, may include a second office visit or consultation via telemedicine
- Patient consultation: may include telemedicine consult or office visit check-in with in-person consult.
- Confirmation of pregnancy termination (either by hCG or ultrasound)

Please see Provider Bulletin for further billing information and related requirements.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B2200472. Jan. 2022. (Accessed Aug. 2024).

FQHC/RHC

Health First Colorado allows telemedicine visits to qualify as billable encounters for Federally Qualified Health Centers (FQHCs), Rural Health Clinic (RHCs), and Indian Health Services (IHS). Services allowed under telemedicine may be provided via telephone, live chat, or interactive audiovisual modality for these provider types.

When a Federally Qualified Health Center or a Rural Health Clinic provides care through telemedicine, the claim must include the modifier GT on line(s) identifying the service(s).

When used by an FQHC or RHC, the modifier GT identifies the services as being delivered through telemedicine modality. There is no enhanced payment to FQHCs and RHCs when using the modifier GT.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

For Health First Colorado a billable encounter at an FQHC and RHC is an in person or telemedicine face to face visit with a Health First Colorado member. Telemedicine services are limited to the procedure codes identified in the Telemedicine Billing Manual. Services provided via telemedicine must use modifier GT on the claim. All other claim submission information is the same.

Additionally, modifiers FQ and FR can be added to the claim:

FQ: The service was furnished using audio-only communication technology.
FR: The supervising practitioner was present through two-way, audio/video communication technology.

SOURCE: CO FQHC & RHC Billing Manual 5/24. (Accessed Aug. 2024).

The visit definition for a FQHC includes interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounters in accordance with Section 8.095. Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care in accordance with Section 8.095.

SOURCE: Colorado Adopted Rule 8.700.1. (Accessed Aug. 2024).

Visit for a RHC means a face-to-face encounter, or an interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounter in accordance with Section 8.095 between a clinic client and any health professional providing the services set forth in 8.740.4. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.740.1. (Accessed Aug. 2024).

Long Term Services and Supports (LTSS), Home and Community-based Services (HCBS), Services for Individuals with Intellectual and Developmental Disabilities, Early Childhood Intervention Services

Upon department approval, certain eligibility determinations, assessments, referrals, and monitoring contacts may be completed by case managers at an alternate location, via telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the case manager or Client (e.g. natural disaster, pandemic, etc.).

SOURCE: 10 CCR 2505-10 8.393; 8.506.4.B; 8.508.70; 8.509; 8 CCR 1405-1. (Accessed Aug. 2024).

Home and Community-Based Services for Persons with Intellectual and/or Developmental Disabilities Waiver Programs & Targeted Case Management for Home and Community-Based Services Waiver Programs

Targeted case management via telephone and video is listed as allowed. See manual.

SOURCE: CO Dep. of Health Care Policy and Financing, Home and Community-Based Services for Persons with Intellectual and/or Developmental Disabilities Waiver Programs & Targeted Case Management for Home and Community-Based Services Waiver Programs, Last revised 6/23/24, (Accessed Aug. 2024).

Home and Community-Based Services

Home and Community-Based Services Telehealth (HCBS Telehealth) is a method of service delivery of certain HCBS services listed at Section 8.615.2.

SOURCE: 10 CCR 2505-10 8.615.1 (M). (Accessed Aug. 2024).

Members eligible to use HCBS Telehealth are those enrolled in the waivers and services as defined in this rule at Section 8.7100. Additional requirements include:

The Case Management Agency shall ensure the use of HCBS Telehealth is the choice of the Member through the Person-Centered Support Planning process by indicating the Member’s choice to receive HCBS Telehealth in the Department prescribed IT system.
Through the Person-Centered Support Planning process, the Case Management Agency shall identify and address the benefits and possible detriments to Members choosing to use HCBS Telehealth for service delivery.
HCBS Telehealth delivery must be prior authorized and documented in the Member’s Person-Centered Support Plan.
Telehealth as a service delivery method for authorized HCBS Waiver Services, shall not interfere with any individual rights or be used as any part of a Rights Modification plan.
Provider Agencies that provide HCBS Telehealth services shall establish and maintain documented policies on the use of Telehealth services that comply with Section 8.7559.

HCBS Telehealth may be used to deliver support through authorized HCBS Waiver Services listed at Section 8.7559A. See Sec. 8.7559 for additional information on services authorized for consultation through telehealth, HCBS telehealth exclusions and limitations, as well as HCBS telehealth provider agency requirements, which include that providers that choose to use HCBS Telehealth shall develop and make available a written HCBS Telehealth Policy which includes that providers shall ensure the use of HCBS Telehealth is the choice of the Member. HCBS Waiver providers must be able to use a technology solution that allows real-time interaction with the Member which may include audio, visual and/or tactile technologies. Providers shall not use HCBS Telehealth to address a Member’s emergency needs.

HCBS Telehealth does not include reimbursement for the purchase or installation of Telehealth equipment or technologies. HCBS Waiver service providers utilizing Telehealth shall follow all billing policies and procedures as outlined in the Department’s current waiver billing manuals and rates/fees schedules. This includes the prohibition on collecting copayments or charging Members for missing set times for services.

SOURCE: 10 CCR 2505-10, Sec. 8.7202H, 8.7408, 8.7559. (Accessed Aug. 2024).

Adult Day Services (ADS)

Adult Day Services (ADS) may be provided out of an Adult Day Services Center or through Non-Center-Based means including Telehealth.

Telehealth Adult Day Services are provided through virtual means in a group or on an individual basis. Telehealth ADS are ways for participants to engage in activities, with their community, and connect to staff and other ADS participants virtually or over the phone, only if a participant does not have access or the ability to use video chat technology. Services provided through Telehealth are not required to provide nutrition services. See rules for staffing, documentation, billing and written policy requirements specific to use of telehealth ADS.

SOURCE: 10 CCR 2505-10 8.491; 8.7504B. (Accessed Aug. 2024).

Telehealth Day Habilitation services

Telehealth Specialized Habilitation services includes provider-hosted virtual meetings, groups, and activities where Members virtually engage and interact with provider staff, volunteers, and other Members.

Telehealth Supported Community Connections services includes virtual meetings, groups and activities, that are hosted by non-provider entities where Members virtually engage and interact with persons without disabilities other than those individuals who are providing services to the Member.

SOURCE: 10 CCR 2505-10 Sec. 8.7516. (Accessed Aug. 2024).

Program of All-Inclusive Care for the Elderly (PACE)

Telehealth is allowed for the provision of services delivered under PACE. The PACE organization must visit each participant in-person or via telehealth across all care settings as often as the participant’s condition requires, but no less than once each calendar month. If the PACE organization provides these visits via telehealth, the PACE organization must ensure the telehealth delivery option meets the following requirements:

Participants must have an informed choice between in-person and telehealth services;
The use of the telehealth delivery option will not prohibit or discourage the use of in-person services;
Telehealth will not be used for the provider’s convenience; and
Telehealth must be provided using technology compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security and Breach Notification Rules.

The telehealth permissions in this section do not apply to the in-person assessment and reassessment requirements as described in 8.497.8.G. In addition to the medical record content requirements set forth in 42 CFR Â§ 460.210(b), the PACE organization must document whether a service or visit was provided in person or via telehealth.

SOURCE: 10 CCR 2505-10, Section 8.497 . (Accessed Aug. 2024).

Mobile Crisis Response (MCR) Services

MCR services may be provided via Telemedicine in accordance with Section 8.095 by any one (1) member of the MCR provider’s team, where appropriate. The initial Telemedicine face-to-face crisis response must include at least (1) in-person responder from the MCR team.

SOURCE: 10 CCR 2505-10 8.020. (Accessed Aug. 2024).

Behavioral Health

“Session” means a face-to-face, telehealth, or audio-only interaction of the individual and personnel. Session may include but is not limited to individual therapy, group therapy, medication-assisted treatment education and/or monitoring, family therapy, peer professional services, educational/occupational groups, recreational therapy, intake, discharge, service planning, and other therapies.

The BHE may use telehealth methods for the provision of services under these regulations except for services that specifically require in-person contact. If a service is allowable via telehealth according to state and federal regulations, appropriate methods will be noted within the applicable endorsement Chapter. If an individual prefers to receive services in-person and the BHE does not offer the appropriate service in-person, the BHE shall refer the individual to another entity that offers the service in-person.

If the BHE uses telehealth methods, it must develop and implement policies and procedures regarding telehealth services, including:

Collection of required signatures;
Training for personnel specific to the modality or manner for determining competence with the modality;
Procedure for personnel response if an individual experiences an emergency while receiving services via telehealth, including collection of information about the individual’s remote location for each session;
Confidentiality protocols designed to protect the individual’s privacy in accordance with state and federal law; and
Specification as to whether policies apply to the BHE as a whole, a physical location, or a specific endorsement, as appropriate.

Services provided via telehealth methods must be documented in the individual’s record, consistent with documentation requirements for in-person services.

Screenings should be conducted in-person unless contraindicated. If contraindicated, screenings may be conducted via audio-visual or audio only telehealth. Clinical rationale must be documented in the case of a telehealth screening.

A peer support professional may provide services in a variety of settings, if permitted access, that may include but are not limited to audio-visual or audio-only telehealth.

Early intervention services may be delivered via telehealth in accordance with the standards set in part 2.9 of these rules.

Various outpatient services may be delivered via in-person, audio-visual telehealth, or audio-only telehealth format in accordance with part 2.9 of these rules.

Walk-In crisis services follow-up communication may be conducted face-to-face, via telehealth, or via telephone only, based on an individual’s clinical need and preferences. Telehealth may be used to secure expertise for individuals served by the mobile crisis response team with a physical or I/DD.

If telehealth services do not best meet the needs of the individual and the BHE endorsed to provide DUI/DWAI programming cannot accommodate in-person services, the BHE must refer the individual to a provider that can meet the individual’s needs. Level II Four Plus must be completed as in-person services. 1. Telehealth may only be utilized if clinically indicated for the individual, or if the individual is unable to attend in-person. Documentation must be present in the individual record stating why telehealth was utilized.

BHE policies and procedures should include how telehealth services are deployed, how individual preference for in-person services are addressed, and when based on diagnosis or other need, telehealth services are not appropriate.

Essential behavioral health safety net providers offering outpatient behavioral health services must have in-person service offerings in addition to any telehealth services the agency may elect to provide.

SOURCE: 2 CO Code of Regulation 502-1, 1.2, p. 18, 2.9, p. 40, 2.12, p. 49, 3.2, p. 91, 4.2, p. 94, 4.3, p. 96, 4.6, p. 104, 4.7, p. 106, 6.3, p. 149, 151, 156, 10.5, p. 184, 10.9, p. 193, 12.3, p. 284, 12.4, p. 293, 21.6, p. 475. (Accessed Aug. 2024).

School-Linked Health Care Services

School-linked health care services, meaning primary health-care services, behavioral health-care services, oral health-care services, or preventative health-care services, may be delivered through telehealth, mobile services, or referrals for health-care services at a clinic located near school grounds.

SOURCE: CO Statute Sec. 25-20.5-502 as proposed to be amended by SB 24-034 (2024 Session). (Accessed Aug. 2024).

School Health Services

Telehealth codes listed as eligible with GT modifier throughout manual.

SOURCE: CO Dep. of Health Care Policy and Financing, School Health Services, Last revised 7/1/24, (Accessed Aug. 2024).

Doula Services

Doula services are billed using two Healthcare Common Procedure Coding System (HCPCS) procedure codes, two International Classification of Diseases (ICD)-10 diagnosis codes, and a combination of modifier codes if services are delivered via telemedicine. The modifier codes shown below should only be used in circumstances involving telemedicine.

See billing manual for codes that are allowed via telehealth.

Doulas can provide prenatal and postpartum care in variety of settings, including the member’s home, clinics and provider offices, community-based settings or via telehealth. A full list of allowable places of service for doula services are indicated below.

Labor and delivery services (T1033) cannot be provided via telemedicine with Place of Service codes 02 or 10. While doulas must provide in-person labor and delivery support, location can vary.

SOURCE: CO Dep. of Health Care Policy and Financing, Doula Billing Manual, Last revised 8/9/24, (Accessed Aug. 2024).

Pharmacy Services

Some codes are allowed for telemedicine delivery. Refer to the Telemedicine Services web page for more detail.

SOURCE: CO Dep. of Health Care Policy and Financing, Pharmacy Services, Last revised 2/29/24, (Accessed Aug. 2024).

ELIGIBLE PROVIDERS

Any licensed provider enrolled with Colorado Medicaid is eligible to provide telemedicine services within the scope of the provider’s practice.

SOURCE: Colorado Adopted Rule 8.095.3. CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

All distant providers should bill the appropriate procedure code and Place of Service 02 or 10 and FQ or FR modifiers if appropriate on the CMS 1500 paper claim form or as an 837P transaction.

The following distant provider types may bill using modifier GT:

Physician
Clinic
Osteopath
FQHC
Doctorate Psychologist
MA Psychologist
Physician Assistant
Nurse Practitioner
RHC

A primary care provider (PCP) is eligible to be reimbursed as the ‘originating provider’ when present with the patient. In order for a PCP to be reimbursed as a distant provider, the PCP must be able to facilitate an in-person visit in the state of CO if necessary for treatment of the member’s condition.

A specialist is eligible to be an originating provider (if present with the patient) or distant provider.

The distant provider may participate in the telemedicine interaction from any appropriate location.

When the patient is located in a hospital, please use the appropriate place of service code for where the patient is located.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Health First Colorado has expanded the list of providers eligible to deliver telemedicine services to include FQHCs, RHCs, IHS, physical therapists, occupational therapists, home health providers, hospice and pediatric behavioral health providers. Outpatient physical, occupational and speech therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

SOURCE: CO Dept. of Health Care Policy and Financing, Provider Bulletin, June 2023. (Accessed Aug. 2024).

Physical Therapists, Occupational Therapists, Hospice, Home Health Providers and Pediatric Behavioral Health Providers

Physical therapists, occupational therapists, hospice, home health providers and pediatric behavioral health providers are eligible to deliver telemedicine services.

Home Health Agency services and therapies, Hospice, and Pediatric Behavioral Treatment may be provided via telephone-only.
Outpatient Physical, Occupational, and Speech Therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

Telemedicine is covered for behavioral health providers under the capitated behavioral health benefit administered by the Regional Accountable Entities (RAEs). Behavioral health providers should contact their RAE for guidance. Visit the Accountable Care Collaborative Phase II web page for more information.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

RHC/IHS/FQHC

A telemedicine service meets the definition of a face-to-face encounter for a rural health clinic, Indian health service, or federally qualified health center. The reimbursement rate for a telemedicine service provided by a rural health clinic or federal Indian health service or federally qualified health center must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.

SOURCE: CO Statute, Sec. 25.5-5-320. (Accessed Aug. 2024).

FQ: The service was furnished using audio-only communication technology.
FR: The supervising practitioner was present through two-way, audio/video communication technology.

SOURCE: CO Dep. of Health Care Policy and Financing, FQHC/RHC Services, Last revised 5/15/24, (Accessed Aug. 2024).

eHealth Entities

Providers that meet the definition of an eHealth Entity shall enroll as the eHealth specialty. Electronic Health Entity (eHealth Entity) means a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty. eHealth entities:

1. Cannot be Primary Care Medical Providers
  1. Primary Care Medical Provider (PCMP) means an individual physician, advanced practice nurse or physician assistant, who contracts with a Regional Accountable Entity (RAE) in the Accountable Care Collaborative (ACC), with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology.
2. Can be either in-state or out-of-state.

eHealth Entities shall only provide Covered Telemedicine services, including Facilitated Visits. A Facilitated Visit means a Telemedicine visit where the rendering provider is at a distant site and the member is physically present with a support staff team member who can assist the provider with in-person activities. eHealth Entities must maintain a Release of Information in compliance with current HIPAA standards to facilitate communication with the member’s PCMP.

SOURCE: Colorado Adopted Rule 8.095.1, 8.095.3, 8.095.4, 8.095.6. (Accessed Aug. 2024).

As of October 30th, 2022, there is a provider specialty type for Clinic and Non-Physician Practitioner groups that meet the following definition:

An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty. Providers who meet this definition must update their enrollment to this provider specialty type.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

The telemedicine rule 10 CCR 2505-10 8.095 regarding eHealth entities is effective as of October 30, 2022. An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty.

Telemedicine-only providers are to use Specialty Code 878.
Telemedicine and in-person providers will continue to use the appropriate specialty code for their chosen provider type.

SOURCE: CO Department of Health Care Policy and Financing, Health First CO Provider Bulletin B2200485, (Nov. 2022), (Accessed Aug. 2024).

Ambulatory Surgery Centers & Immunizations Manual

For distant provider use procedure code + modifier GT.

SOURCE: CO Dep. of Health Care Policy and Financing, Ambulatory Surgery Centers (ASC) Billing Manual, Last revised 5/18/23, & Immunizations Billing Manual, Last revised 7/5/24, (Accessed Aug. 2024).

ELIGIBLE SITES

If no originating provider is present during a Telemedicine Services appointment, then the location of the originating site is at the member’s discretion and can include the member’s home. However, members can be required to choose a location suitable to delivery of telemedicine services that may include adequate lighting and environmental noise levels suitable for easy conversation with a provider.

Services can be provided via telemedicine between a member and a distant provider when a member is located in their home or other location of their choice.

A specialist is eligible to be an originating provider (if present with the patient) or distant provider.

If practitioners at both the originating site and the distant site provide the same service to the member, both providers submit claims using the same procedure code with modifier 77 (Repeat procedure by another physician).

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Telemedicine can work:

From a provider office: You can connect through video with a provider in another office. Both offices must have telemedicine equipment.
From your home or other location like a library: You may be able to use your mobile phone, tablet or desktop computer to connect to a provider. Health First Colorado will not pay for the equipment.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine”. (Accessed Aug. 2024).

Eligible place of service includes Telemedicine, including interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission). Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.200.3.B.3.D.2.c.7. (Accessed Apr. 2024).

Speech Therapy

Telemedicine POS 02 and Telehealth POS 10 are allowed place of service codes.

SOURCE: CO Department of Health Care Policy and Financing. “Speech Therapy”, 7/24. (Accessed Aug. 2024).

Therapy Providers

POS Code 02 or 10 should be used to report services delivered via telecommunication depending on the location of the member when receiving telehealth services. POS 02 is used when the member is receiving telehealth service in a place that is not their home. POS 10 is used when a member is receiving telehealth services when the member is located in their home.

Outpatient physical, occupational, and speech therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin B2200480. July 2022. (Accessed Aug. 2024).

Physical Therapy and Occupational Therapy

Place of Service Codes

02 – Telemedicine – Not provided in patient’s home (only applicable to certain procedure codes). Refer to the Telemedicine Billing Manual.
10 – Telehealth – Provided in patient’s home. Refer to the Telemedicine Billing Manual.

Telemedicine place of service (POS) code 02 is available for specific procedure codes. Visit the Telemedicine – Provider Information web page for a list of allowed procedure codes.

SOURCE: CO Dep. of Health Care Policy and Financing, Physical Therapy and Occupational Therapy Billing Manual, Last revised 7/24/24, (Accessed Aug. 2024).

Home Health Services

Services shall be provided in the client’s place of residence or one of the following places of service: Services may be provided using interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) instead of in-person contact. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.520.4.B.g. (Accessed Aug. 2024).

Telehealth monitoring is available for members who are eligible through the Home Health benefit and should not be billed as telemedicine. Providers rendering telehealth monitoring should consult the Home Health Billing Manual on the Billing Manuals web page under the CMS 1500 drop-down.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

Family Planning Services

Eligible places of service include telemedicine provided in accordance with Section 8.095.

SOURCE: Colorado Adopted Rule 8.730.3.B. (Accessed Aug. 2024).

FQHC/RHC

FQHCs, RHCs, and IHS providers can serve as an originating site allowing a member to connect with a distant provider that is not affiliated with the originating site. The service must be submitted on a professional service claim form (the 1500). Refer to the Telemedicine Billing Manual for the coverage of the originating site procedure code.

SOURCE: CO Dep. of Health Care Policy and Financing, FQHC/RHC Services, Last revised 5/15/24, (Accessed Aug. 2024).

Doula Services

Labor and delivery services (T1033) cannot be provided via telemedicine with Place of Service codes 02 or 10. While doulas must provide in-person labor and delivery support, location can vary.

Allowed Place of Service Codes

02 – Telehealth Provided Other than in Patient’s Home
10 – Telehealth Provided in Patient’s Home

SOURCE: CO Dep. of Health Care Policy and Financing, Doula Billing Manual, Last revised 8/9/24, (Accessed Aug. 2024).

Pediatric Behavioral Therapies

Place of Service:

02 – Telemedicine (Refer to the Telemedicine Billing Manual)

Telemedicine place of service (POS) code 02 is available for specific procedure codes. Visit the Telemedicine – Provider Information web page for a list of allowed procedure codes.

SOURCE: CO Dep. of Health Care Policy and Financing, Pediatric Behavioral Therapies Billing Manual, Last revised 8/12/24, (Accessed Aug. 2024).

Pharmacy Services

Allowed Place of Service Codes

02 – Telemedicine, other than in patient’s home (only applicable to certain procedure codes, see details below)
10 – Telemedicine, in patient’s home (only applicable to certain procedure codes, see details below)

Telemedicine place of service (POS) codes 02 and 10 are available for specific procedure codes. Refer to the Telemedicine Billing Manual for further details.

SOURCE: CO Dep. of Health Care Policy and Financing, Pharmacy Services Billing Manual, Last revised 2/29/24, (Accessed Aug. 2024).

GEOGRAPHIC LIMITS

No Reference Found.

FACILITY/TRANSMISSION FEE

In some cases, the originating provider site will not be providing clinical services, but only providing a site and telecommunications equipment. In this situation, the telemedicine originating site facility fee is billed using procedure code Q3014.

Originating providers bill as follows:

If the originating provider is making a room and telecommunications equipment available but is not providing clinical services, the originating provider bills Q3014 (the procedure code for the telemedicine originating site facility fee).
If the originating provider also provides clinical services to the member, the provider bills the rendering provider’s appropriate procedure code and bills Q3014.
The originating provider may also bill, as appropriate, on the UB-04 paper claim form or as an 837I transaction for any clinical services provided on-site on the same day that a telemedicine originating site claim is made. The originating provider must submit two separate claims for the member’s two separate services.

Providers eligible for the originating site facility fee include:

Physician
Clinic
Osteopath
FQHC
Doctorate Psychologist
MA Psychologist
Physician Assistant
Nurse Practitioner
RHC

Provider types not listed above may facilitate Telemedicine Services with a distant provider but may not bill procedure code Q3014. Examples include Nursing Facilities, Intermediate Care Facilities, Assisted Living Facilities, etc.

When an originating site bills Q3014 (telemedicine originating site facility fee), there is generally no rendering provider actually involved in the service at the originating site. However, a rendering provider number is still required and must be affiliated with the billing provider. The facility may enter either the member’s usual provider’s number, or another provider number affiliated with that site as the rendering provider. When the member sees a rendering provider at the originating site and also uses the site as the telemedicine originating site, the facility bills the rendered service procedure code and Q3014 for the use of the telemedicine facility. The same rendering provider number is entered in field 19D.

Using modifier GT with specific codes adds $5.00 to the fee listed for the service. A specific list of eligible codes is provided in the manual. Other codes can be billed, but don’t pay the telemedicine transmission fee.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

The state department shall establish rates for transmission cost reimbursement for telemedicine services, considering, to the extent applicable, reductions in travel costs by health care or mental health care providers and patients to deliver or to access such services and such other factors as the state department deems relevant.

SOURCE: CO Revised Statutes 25.5-5-320(3). (Accessed Aug. 2024).

Ambulatory Surgery Centers & Immunizations

Telemedicine: For originating provider use procedure code Q3014.

SOURCE: CO Dep. of Health Care Policy and Financing, Ambulatory Surgery Centers (ASC) Billing Manual, Last revised 5/18/23, & Immunizations Billing Manual, Last revised 7/5/24, (Accessed Aug. 2024).

READ LESS

Connecticut

Last updated 07/17/2024

POLICY

CT Medicaid is required to provide coverage for telehealth …

POLICY

CT Medicaid is required to provide coverage for telehealth services for categories of health care services that the commissioner determines are clinically appropriate to be provided through telehealth, cost effective for the state and likely to expand access to medically necessary services where there is a clinical need for those services to be provided by telehealth or for Medicaid recipients whom accessing healthcare poses an undue hardship.

The commissioner may provide coverage of telehealth services pursuant to this section notwithstanding any provision of the regulations of Connecticut state agencies that would otherwise prohibit coverage of telehealth services. The commissioner may implement policies and procedures as necessary to carry out the provisions of this section while in the process of adopting the policies and procedures as regulations.

SOURCE: CT General Statute 17b, Sec. 245e. (Accessed Jul. 2024).

To the extent permissible under federal law, the commissioner shall provide Medicaid reimbursement for services provided by means of telehealth to the same extent as if the service was provided in person.

SOURCE: CT General Statute 17b, Sec. 245g. (Accessed Jul. 2024).

Effective for dates of service on and after May 12, 2023, which is the first day after the federal COVID-19 public health emergency declaration ends, in accordance with sections 17b-245e and 17b-245g of the Connecticut General Statutes, the Department of Social Services (DSS) is issuing new guidance for services eligible for reimbursement under the Connecticut Medical Assistance Program (CMAP) when rendered via telehealth. DSS will continue to reimburse for specified services when rendered via telehealth as detailed in Provider Bulletin 2023-38 and on the CMAP Telehealth Table. This guidance applies to services rendered under CMAP for all HUSKY Health members.

Telehealth includes:

telemedicine (synchronized audio-visual two-way communication services) and,
where specified by DSS, audio-only two-way synchronized communication services delivered via telephone.

DSS’ continued expectation is that enrolled CMAP providers will perform clinically appropriate services including, but not limited to, ensuring timely access to in-person services when medically necessary or requested by the HUSKY Health member for optimum quality of care. Therefore, all enrolled billing entities must have the capacity to deliver services in-person and must provide services in-person to the full extent that is clinically appropriate for their patients and to the full extent necessary if the HUSKY Health member does not consent to receiving one or more services via telehealth. Having the capacity means that the provider must have a physical location in CT, (or an approved applicable border state as approved as part of enrollment) where the provider has a room or set of rooms to see members in-person and can maintain the member’s privacy and confidentiality during the visit.

All applicable federal and state requirements for the equivalent in-person service apply to telehealth services. Therefore, consistent with all services billed to CMAP, all telehealth services must meet the statutory definition of medical necessity in section 17b-259b of the Connecticut General Statutes and all other applicable federal and state statutes, regulations, requirements, and guidance.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Jul. 2024).

Connecticut’s Medical Assistance Program will not pay for information or services provided to a client by a provider electronically or over the telephone. However, there is an exception for case management behavioral health services for clients age eighteen and under.

SOURCE: CT Provider Manual. Physicians and Psychiatrists. Sec. 17b-262-342. Pg. 9, Oct. 2020; CT Provider Manual. Psychologists. Sec. 17b-262-472. Oct. 2020. Pg. 7; & CT Provider Manual. Behavioral Health. Sec. 17b-262-918. Oct. 2020. Pg. 6. (Accessed Jul. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See specified services reimbursed when rendered via telehealth as detailed in Provider Bulletin 2023-38 and on the CMAP Telehealth Table. Comprehensive information regarding the specific procedure codes eligible are posted on the CMAP Telehealth Webpage as well. This web page will provide information on telehealth requirements, approved procedure codes, required modifiers, specific policy criteria and/or limitations, effective dates, and other telehealth policy information, including the Telehealth FAQs.

Providers are responsible for verifying coverage of a specific procedure code as a telehealth service as well as a covered service on their applicable fee schedule prior to delivering and billing CMAP for the service. Billing for a service via telehealth that is not listed as an approved service on the CMAP Telehealth Table or listed as a covered service on the applicable fee schedule or failure to adhere to the policy and applicable telehealth criteria/limitations, may result in a denied claim or may be at-risk for a financial adjustment during a post-payment review.

Services rendered via telehealth will be reimbursed at the same rate as if the service was rendered in-person. Providers must refer to their applicable reimbursement methodology or fee schedule to ensure that the service identified as eligible to be rendered as a telehealth service is payable for their specific provider type and the reimbursement rate.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Jul. 2024).

Modifiers: One of the following telehealth modifiers should be used when submitting claims:

Modifier GT: Via interactive audio and video telecommunication systems
Modifier 95: Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system
Modifier FQ: This service was furnished using audio-only communication technology (use with applicable behavioral health services )

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

Effective June 12, 2023, providers must ensure that the provision of 90853 (group psychotherapy) is performed via telemedicine (synchronized audio-visual) only. Providers are encouraged to monitor the CMAP website (www.ctdssmap.com) frequently for updates to the DSS Telehealth policy and to ensure that you are accessing the most current version of the CMAP Telehealth Table.

SOURCE: CT Dept. of Social Services. Provider Message. June 2023. (Accessed Jul. 2024).

Effective June 21, 2023, and forward, providers eligible for reimbursement for procedure code T1017 (Targeted case management, 15 minutes) may perform this service via audio-only or telemedicine under the CMAP Telehealth policy.

SOURCE: CT Dept. of Social Services. Provider Message. June 2023. (Accessed Jul. 2024).

Effective for dates of service May 12, 2023, and forward, Medical Equipment Devices (MEDS) providers must comply with the face-to-face (F2F) requirements for certain DME as specified by 42 CFR 440.70. Compliance with this requirement includes the provision of the F2F encounter via telehealth as specified by 42 CFR 440.70(f)(6) when the service billed complies with the telehealth policies as outlined and specified by DSS.

Effective for dates of service May 12, 2023, and forward, physicians can conduct assessments for complex rehabilitative technology (CRT) equipment either in person or via synchronized telemedicine with the assistance of the physical therapist (PT) or occupational therapist (OT) which must be in person with the HUSKY Health member. The requirement of the PT or OT in-person with the member is to ensure the demonstration of the equipment and any features on a customized wheelchair will meet the clinical needs of members residing in skilled nursing facilities.

SOURCE: CT Policy – Provider Bulletin 2023-33. Apr. 2023. (Accessed Jul. 2024).

Effective for dates of service October 16, 2023, and forward, providers eligible for reimbursement for procedure code S0199 (Med abortion inc all ex drug) may perform this service via telemedicine only (synchronized audio-visual), under the CMAP Telehealth policy.

SOURCE: CT Policy – Provider Important Message. Oct. 2023. (Accessed Jul. 2024).

In addition to procedure code S0199, providers are permitted to provide & bill for the MAB medications (S0190 & S0191) as part of the overall MAB service.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

Opioid Treatment Programs are required to perform a complete, fully documented physical evaluation prior to admission. The program physician may render the physical evaluation component of MAT services via telemedicine only when all of the following are met:

The CMAP member’s originating site is another CMAP-enrolled Opioid Treatment Program (Methadone Maintenance Clinic) that is part of the same billing entity as the originating site;
The originating site is providing all the other required components of MAT services including the intake and psychiatric evaluation;
As required by 42 CFR 8.12(f), an authorized healthcare professional under the supervision of a program physician is present with the member at the originating site; and
The distant site provider must be located at a different service location/address than the originating site.

Induction services must always be rendered face-to-face (in-person) and only after the physical and psychiatric evaluation has been performed. Once a CMAP member has been inducted, routine psychotherapy services may be rendered via telemedicine.

MAT services that may be rendered via telemedicine include medication management and psychotherapy services.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

CT does not pay for information or services furnished by a licensed behavioral health clinician to the client electronically or over the telephone, except for case management behavioral health services for clients age eighteen and under.

SOURCE: CT Provider Manual. Behavioral Health. Sec. 17b-262-918. Oct. 2020. Pg. 6. (Accessed Jul. 2024).

Outpatient Hospitals

With the exception of nutritional counseling and PT/OT/SLP services, medical telehealth services are considered professional services and therefore no reimbursement will be provided to the hospital. Behavioral health telehealth services, including medication management, are considered an all-inclusive rate to the hospital and therefore professional fees will not be paid separately.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. & CMAP Telehealth Table. (Accessed Jul. 2024).

Outpatient hospitals may bill for nutritional counseling services when rendered via telemedicine under procedure code G0463 – “clinic visit”. It should be noted that procedure code G0463 is approved for telemedicine nutritional counseling services only and that nutritional counseling can only be billed via telemedicine and cannot be billed via audio-only.

SOURCE: CT Medicaid Assistance Program Telehealth FAQ (May 2023), p. 3. (Accessed Jul. 2024).

Nursing Facility and Hospital Care

Subsequent nursing facility care services are limited to one telemedicine visit every 30 days. Subsequent hospital care services are limited to one telemedicine visit every 3 days.

End-State Renal Disease Services (ERSD)

ESRD services with multiple visits per month (two or more) may be reimbursed when rendered as telemedicine, however; at least one (1) visit must be rendered in-person to examine the vascular access site.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

School Based Child Health Providers

School Based Child Health Providers are limited to the following services: 90791, 90832, 90847, 90853, H0031, H2014, 92507, 92521, 92522, 92523, 97110 – Refer to the policy guidelines in the CMAP Telehealth Table.

SOURCE: CT Policy – Provider Bulletin 2023-23. March 2023. & CMAP Telehealth Table. (Accessed Jul. 2024).

Targeted Case Management for Integrated Care for Kids (InCK) in New Haven

Monitoring and follow-up activities include making necessary adjustments in the care plan and related changes in the services performed by the provider, which may be performed by staff face-to-face, telehealth, or telephone contact with the individual; by chart review; by case conference; by collateral contact with individuals, family members, providers, legal representatives, or other persons or entities for the benefit of the Medicaid member; or any combination thereof. The care plan must be reviewed every 90 days and adjusted if needed. See bulletin for more information.

SOURCE: CT Policy – Provider Bulletin 2023-55. Jul. 2023. (Accessed Jul. 2024).

Sick Visits

Sick Visits for adults and children are allowed to be performed via telehealth. Refer to CMAP Telehealth Table.

Hospice and Home Health Services, and Well Visits

Hospice and home health services, in addition to Well Visits, cannot be performed via telemedicine. These services must be rendered in person. Refer to Provider Bulletin 2023-38.

SOURCE: CT Medicaid Assistance Program Telehealth FAQ (May 2023), p. 3. (Accessed Jul. 2024).

Children’s Mental Health Urgent Crisis Centers Services

Effective April 1, 2024, DSS will enroll and pay certified providers to deliver children’s mental health urgent crisis services. Claims submitted from DCF certified service location that is enrolled as a CMAP provider will be reimbursed for in-person or services performed via telehealth when billing identified billing/procedure codes listed in Provider Bulletin 2024-16.

SOURCE: CMAP Provider Bulletin 2024-16. Mar. 2024. (Accessed Jul. 2024).

ELIGIBLE PROVIDERS

Only the following categories of CMAP-enrolled providers may provide and bill for such psychotherapy services or psychiatric diagnostic evaluations within their scope of practice via telemedicine:

Physician
Physician Assistant
Advanced Practice Registered Nurses
Licensed Behavioral Health Clinicians (defined below and which includes only the following: Licensed Psychologists, Licensed Clinical Social Workers, Licensed Marital and Family Therapists, Licensed Professional Counselors, and Licensed Alcohol and Drug Counselors)
Behavioral Health Clinics – including Enhanced Care Clinics (ECCs)
Behavioral Health Federally Qualified Health Centers (FQHCs)
Medical Clinics – excluding School Based Health Centers (SBHCs)
Rehabilitation Clinics
Outpatient Hospital Behavioral Health (BH) Clinics
Outpatient Psychiatric Hospitals
Outpatient Chronic Disease Hospitals (CDHs)

Modifiers GT is used when the member’s originating site is located in a healthcare facility or office; or modifier 95 Is used when the member is located at home.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

Medication Assisted Treatment

Eligible providers:

Physician
APRNs
PAs
Behavioral Health Clinics

Medication Management

Eligible Providers:

Physicians
PAs
APRNs
Medical Clinics – excluding SBHCs
Behavioral Health Clinics – including ECCs
Behavioral Health FQHCs
Outpatient Hospital BH Clinics
Outpatient Chronic Disease Hospitals

Eligible providers for out of state surgery and homebound patients include:

Physicians
PAs
APRNs
CNMs
Podiatrists

Eligible providers to determine if patient to be homebound and/or provide and bill for such service:

Physicians
PAs
APRNs
CNMs
Podiatrists

For homebound patients, provider must document the reason the member is being determined homebound.

Documentation must be maintained by both the originating site provider and the distant site provider to substantiate the services provided. Originating site documentation must indicate the member received or has been referred for telehealth services.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

Medication Assisted Treatment – Opioid Treatment Program

The distant site provider cannot bill for the physical evaluation component rendered via telemedicine.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

FQHCs

Federally Qualified Health Centers (FQHCs) are eligible to bill their encounter rate when an approved, medically necessary telehealth service is rendered. FQHCs must use the services identified on the Telehealth Table in combination with their approved scope of service to identify the services eligible to be rendered using telehealth. FQHCs must continue to bill HCPCS code, T1015 and all eligible telehealth procedure codes to reflect all of the services rendered during the telehealth visit.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

ELIGIBLE SITES

There is no limitation on the originating site for a member receiving individual therapy, family therapy or psychotherapy with medication management.

Psychiatric diagnostic evaluations may be rendered via telemedicine only if the member is located at a CMAP-enrolled originating site.

Modifiers GT is used when the member’s originating site is located in a healthcare facility or office; or modifier 95 Is used when the member is located at home.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020, (Accessed Jul. 2024).

Place of Service/Facility Type Code – Bill the appropriate POS/FTC code that is applicable to the location of the member at the time of the telehealth service.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

A practitioner who is enrolled with CMAP as an independent provider or as part of an independent provider group, or as a FQHC or outpatient hospital and maintains an approved service location as part of the CMAP enrollment, has the flexibility to perform eligible telehealth services even when the performing/rendering practitioner is not physically in-person at one of the enrolled CT or border service locations at the time of the service, so long as the practitioner complies with all applicable state and federal requirements.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Jul. 2024).

Medication Assisted Treatment

Due to Opioid Treatment Programs (Methadone Maintenance Clinics) receiving a daily payment rate for all MAT services provided, the daily payment rate will continue to be paid to the originating site only. The distant site provider must be located at a different service location/address than the originating site.

SOURCE: CT Policy – Provider Bulletin 2020-09. March 2020. (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The code (Q3014) for an originating site facility fee is not listed as eligible on the CMAP Telehealth Table.

SOURCE: CMAP Telehealth Table. (Accessed Jul. 2024).

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Delaware

Last updated 07/26/2024

POLICY

DMAP covers medically necessary telehealth services and procedures covered …

POLICY

DMAP covers medically necessary telehealth services and procedures covered under the Title XIX State Plan. Qualifying practitioner services include any covered State Plan service that would typically be provided to an eligible individual in an inperson setting by an enrolled practitioner. Telehealth is not limited based on the diagnosed medical condition of the eligible recipient. All telehealth services must be furnished within the limits of provider program policies and within the scope and practice of the referring provider’s and distant telehealth practitioner’s professional standards as described and outlined in DMAP Provider Manuals. The service provided by the consulting/rendering provider or distant telehealth practitioner must be a service covered by DMAP. If a service is not covered in a face-to-face setting, it is not covered if provided through telehealth. A service provided through telehealth is subject to the same program restrictions, limitations, and coverage exist for the service when not provided through telehealth.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2, pg. 78. (Accessed Jul. 2024).

DMAP will reimburse up to three (3) different consulting/distant telehealth practitioners for separately identifiable telehealth services provided to a member per date of service.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.3, pg. 79; Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 14. (Accessed Jul. 2024).

The same procedure codes and rates apply as for services delivered in person (enrolled providers will bill Usual and Customary). Practitioners should use 02 Modifier as Place of Service for all telehealth charges. When billing the DMAP, the provider must use the appropriate CPT® procedure codes.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2, 16.6.5.2.1-3, pg. 78-80. (Accessed Jul. 2024).

The GT modifier (which indicates the service occurred via interactive audio and video telecommunication system) can be used for Early and Periodic Screening, Diagnostic and Treatment Services through the School Based Health Services program in Group Physical Therapy treatment utilizing code 97150 + the GT modifier.

SOURCE: DE Medical Assistance Program. School Based Health Services Specific Policy Manual, pg. 53 & 57 (4/1/16). (Accessed Jul. 2024).

The referring provider is not required to be present at the originating site, however the recipient of the services must be present. The Distant Site provider must be located within the continental United States.

Reimbursement to the referring provider will only occur when providing a separately identifiable covered service.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Ch. 16.5.1, 16.3.4, & 16.6.2, pg. 75-78. & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Jul. 2024).

Except for instances listed in 24 Del.C. Chapter 60, health-care providers may not deliver health-care services by telehealth and telemedicine in the absence of a health-care provider-patient relationship. A health-care provider-patient relationship may be established either in-person or through telehealth but must meet the requirements of Del.C. 24 §6003.

Consent is required to assure that the patient is a willing participant in the telehealth delivered service and to assure that the recipient retains a voice in their treatment plan. The patient must be informed and given an opportunity to request an in-person assessment before receiving a telehealth assessment. This consent must be documented in the patient’s record and must identify that the covered medical service was delivered by telehealth. The recipient must be able to adequately communicate, either directly or through a representative, with the originating and distant site practitioners.

The provision of services through telehealth must include accommodations, including interpreter and audio-visual modification, where required under the ADA, to ensure effective communication.

The distant site provider or other coverage must be available for appropriate followup care with the patient.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Ch. 16.4.1-2, 16.5.2, pg. 75-76 (Accessed Jul. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The service must be medically necessary, written in the patient’s treatment plan and, follow generally accepted standards of care. The service provided by the distant provider must be a service covered by DMAP.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.4.1, 16.6.2, pg. 75, 78 & Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Jul. 2024).

Interactive audio and video telecommunications can be used for group physical therapy in the Early and Periodic Screening, Diagnostic and Treatment Services through the School Based Health Services program for group physical therapy treatment.

SOURCE: DE Medical Assistance Program. School Based Health Services Specific Policy Manual, pg. 53 & 57 (4/1/16). (Accessed Jul. 2024).

Tele-Dentistry

Synchronous real-time tele-dentistry services must be provided in accordance with the recommendations provided by the American Dental Association. The evaluation is limited to a specific oral health problem or complaint.

SOURCE: DE Medical Assistance Program. Adult Dental Program Services Provider Specific Manual. 7/21/23. Sec. 4.2. p. 7-8 (Accessed Jul. 2024).

Adult Behavioral Health Service

Rate Methodologies for the CPT codes under the telemedicine section of the State Plan for Adult Behavioral Health Services are paid at a lower rate and provided in the manual.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. p. 14 (Accessed Jul. 2024).

Durable Medical Equipment

The face-to-face encounter may occur through telehealth; as implemented by DMAP. In addition, the face-to-face encounter occurred through telehealth may be performed by any of the practitioners described above with the exception of certified nurse-midwives.

SOURCE: DE Medical Assistance Program, Durable Medical Equipment Provider Specific Manual, 3.1.6, p. 20 (Feb. 26, 2024). (Accessed Jul. 2024).

Personal Assistance Services Agencies, Home Health Agencies and Aides

Follow-up visits, patient reassessments, and supervisory visits are authorized to be completed by telehealth mechanism.

SOURCE: 16 DE Admin. Code 3345, 3350, 3351. (Accessed Jul. 2024).

ELIGIBLE PROVIDERS

In order to provide telehealth under DMAP, providers at both the originating and distant site must be enrolled with DMAP and must meet all requirements for their discipline as specified in the Delaware Code and the Medicaid State Plan. For services delivered through telehealth technology to be covered, referring providers and distant telehealth practitioners (including out-of-region practitioners) must:

Act within their scope of practice;
Be licensed to provide telehealth services for which they bill DMAP in Delaware, or the State in which the provider is located if allowed under Delaware State law to provide telehealth services without a Delaware license through the Interstate Medical Licensure Compact or otherwise;
Be in good standing in all states in which provider is licensed;
Not be the subject of an administrative complaint or under investigation by another state’s licensing authority or board;
Be enrolled with DMAP; and
Have provider billing numbers (NPI and Taxonomy).

Distant telehealth practitioners may also need to enroll with the Department of Services for Children, Youth and their Families (DSCYF), Division of Prevention and Behavioral Health Services (DPBHS), and Division of Substance Abuse and Mental Health (DSAMH) as appropriate to provide and be reimbursed for behavioral health services.

The distant telehealth practitioner must be located within the continental United States. As required by §6505 of the Affordable Care Act, DMAP will not make any payments for items or services provided under the State Plan or under a waiver to any financial institution or entity located outside of the United States.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.3, pg. 74-75. (Accessed Jul. 2024).

To receive payment for services delivered through telemedicine technology from DMAP or MCOs, healthcare practitioners must:

Act within their scope of practice;
Be licensed (in Delaware, or the State in which the provider is located if exempted under Delaware State law to provide telemedicine services without a Delaware (license) for the service for which they bill DMAP;
Be enrolled with DMAP/MCOs;
Be located within the continental United States;
Be credentialed by DMMA-contracted MCOs, when needed;
Submit a DMMA Disclosure Form.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. Pg. 11 (Accessed Jul. 2024).

Eligible distant site providers include:

Inpatient/outpatient hospitals (including ER)
Physicians (or PAs under the physician’s supervision)
Certified Nurse Practitioners
Nurse Midwives
Licensed Psychologists
Licensed Clinical Social Workers
Licensed Professional Counselors of Mental Health
Speech Language Therapists
Audiologists
Other providers as approved by the DMAP

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8. Pg. 12 (Accessed Jul. 2024).

ELIGIBLE SITES

Originating Site refers to where the patient is located at the time health care services are provided to the patient by means of telehealth. An approved originating site may include the DMAP member’s place of residence, day program, or alternate location in which the member is physically present, and telehealth can be effectively utilized.

Distant Site refers to the site at which a health care practitioner, legally allowed to practice in the state of Delaware or the state in which the provider is located if allowed under Delaware State law to provide telehealth services without a Delaware license through the Interstate Medical Licensure Compact or otherwise, is located while providing health care services by means of telehealth.

All telehealth sites, both originating and distant sites, must have a written procedure detailing a contingency plan for when a failure or interoperability of the transmission or other technical difficulties render the service undeliverable. Telehealth services are not billable to DMAP or MCOs when technical difficulties preclude the delivery of part or all of the telehealth session.

The referring provider’s medical records must document all components of the services being billed. All distant telehealth practitioners are required to develop and maintain written documentation in the form of evaluations and progress notes, the same as if the documentation had originated during an in-person visit or consultation, including the mode of communication (telehealth). Distant telehealth practitioners may opt to use electronic medical records in place of paper-based written records.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.2.5-6, 16.5.3.7, 16.5.4.1-2, pg. 73-74, 77. (Accessed Jul. 2024).

An originating site refers to the facility in which the Medicaid patient is located at the time the telemedicine service is being furnished. An approved originating site may include the DMAP member’s place of residence, day program, or alternate location in which the member is physically present and telemedicine can be effectively utilized.

Medical Facility Sites:

Outpatient Hospitals
Inpatient Hospitals
Federally Qualified Health Centers
Rural Health Centers
Renal Dialysis Centers
Skilled Nursing Facilities
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
Intermediate Care Facilities/Institutions for Mental Diseases (ICF/IMDs)
Outpatient Mental Health/Substance Abuse Centers/Clinics
Community Mental Health Centers/Clinics
Public Health Clinics
PACE Centers
Assisted Living Facilities
School-Based Wellness Centers
Patient’s Home (must comply with HIPAA, privacy, secure communications, etc., and does not warrant an originating site fee)
Other Sites as approved by the DMAP

Medical Professional Sites:

Physicians (or Physicians Assistants under the supervision of a physician)
Certified Nurse Practitioners
Medical and Behavioral Health Therapists

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1. 8. pg. 11 & 12 (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

There are no geographical limitations within Delaware regarding the location of an originating site provider.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 12. (Accessed Jul. 2024).

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.3.4 pg. 75. (Accessed Jul. 2024).

FACILITY/TRANSMISSION FEE

DMAP reimburses the originating site fee for telehealth services per completed transmission to licensed practitioners that are enrolled in DMAP. A facility fee for the originating site is covered, unless the originating site is the patient’s home. Although a home can be considered an originating site, it is not eligible for reimbursement of the originating site fee.

DMAP will reimburse the originating site fee for up to three (3) different originating site providers for separately identifiable telehealth services provided to a member per date of service. Each originating site provider will only be reimbursed one (1) originating site fee per member per day. DMAP will not reimburse the referring provider at the originating site on the same date of service unless the referring provider is billing for a separate identifiable covered service. Medical records must document that all components of the service being billed were provided to the recipient.

Practitioners should use HCPCS Level II procedure code Q3014 when billing for the facility fee.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Sec. 16.6.2-3, 16.6.5.1.1, pg. 79. (Accessed Jul. 2024).

A facility fee is covered for originating sites.

Facility fees for the distant site are not covered.

Only one facility fee is permitted per date, per member.

SOURCE: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 1, 2016. Sec. 1.8, p. 11. (Accessed Jul. 2024).

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District of Columbia

Last updated 06/05/2024

POLICY

DC Medicaid must reimburse for health care services through …

POLICY

DC Medicaid must reimburse for health care services through telehealth if the same service would be covered when delivered in person.

SOURCE: DC Code Sec. 31-3863 (Accessed Jun. 2024).

The DC Medical Assistance Program will reimburse telemedicine services, if the Medicaid beneficiary meets the following conditions:

Be enrolled in the DC Medicaid Program;
Be physically present at the originating site at the time the telemedicine service is rendered; and
Provide written or verbal consent to receive telemedicine services in lieu of in-person healthcare services, consistent with all applicable DC laws.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.5, Physicians Billing Manual. DC Medicaid. Jan. 2024, Sec. 15.2. P. 51 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 2, Clinic Billing Manual (Sept. 2023) 15.2, P. 49; Behavioral Health Billing Manual (Feb. 2024) 14.2, p. 68. FQHC Billing Manual (Oct. 2023), 15.2, P 51. (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Medicaid shall cover and reimburse for healthcare services appropriately delivered through telehealth if the same services would be covered when delivered in person.

SOURCE: DC Code Sec. 31-3863 (Accessed Jun. 2024)

Covered Services:

Evaluation and management
Consultation of an evaluation and management of a specific healthcare problem requested by an originating site provider
Behavioral healthcare services including, but not limited to, psychiatric evaluation and treatment, psychotherapies, and counseling
Speech therapy (Outpatient Hospital Billing Guide states: Rehabilitation services including speech therapy)

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.11 & Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.7. P. 53-54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.7, P. 51-52. FQHC Billing Manual, DC Medicaid 15.6.1, P. 53-54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.7, p. 70-71. & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 5-6, Outpatient Hospital Billing Guide, 15.8.5, p. 75 (Apr. 2024), Inpatient Hospital Billing Guide, 11.7, p. 62-63 (Apr. 2024), Long-Term Care Billing Manual, 15.7, p. 53-54 (Sept. 2023). (Accessed Jun. 2024).

The provider shall determine if the service can reasonably be delivered at the standard of care via telemedicine.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.7. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.7, P. 51-52 . FQHC Billing Manual, DC Medicaid 15.6.1, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.7, p. 71, Inpatient Hospital Billing Guide, 11.7, p. 63 (Apr. 2024), L ong-Term Care Billing Manual, 15.7, p. 54 (Sept. 2023) (Accessed Jun. 2024).

Distant site providers may only bill for the appropriate codes outlined.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.12.(Accessed Jun. 2024).

Telemedicine listed as a covered service in the following manuals, but no other information is provided.

Education-Related Services

Office of the State Superintendent of Education shall only bill for distant site services that are allowable healthcare services to be delivered by the individual fee-for-service providers delivering Strong Start DC Early Intervention Program (DC EIP) services under them and can be delivered at the standard of care via telemedicine.

The following reimbursement parameters apply for services delivered under the Office of the State Superintendent of Education through the Strong Start DC Early Intervention Program:

The LEA shall only bill for distant site services that are allowable healthcare services to be delivered at DCPS/DCPCS and can be delivered at the standard of care via telemedicine;
The LEA shall provide an appropriate primary support professional to attend the medical encounter with the member at the originating site. In instances where it is clinically indicated, an appropriate healthcare professional shall attend the encounter with the member at the originating site.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 5. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.6. P. 53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.6, P. 51. FQHC Billing Manual, DC Medicaid 15.6, P. 53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.6, p. 70 , Inpatient Hospital Billing Guide, 11.6, p. 62 (Apr. 2024), L ong-Term Care Billing Manual, 15.6, p. 53 (Sept. 2023) (Accessed Jun. 2024).

Excluded Services

The Program will not reimburse telemedicine providers for the following:

Incomplete delivery of services via telemedicine, including technical interruptions that result in partial service delivery.
When a provider is only assisting the beneficiary with technology and not delivering a clinical service.
For a telemedicine transaction fee and/or facility fee.
For store and forward and remote patient monitoring

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6, Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.8. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.8, P. 52. FQHC Billing Manual, DC Medicaid 15.6.2, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.8, p. 71, Outpatient Hospital Billing Guide, 15.8.6, p. 75 (Apr. 2024), Inpatient Hospital Billing Guide, 11.8, p. 63 (Apr. 2024), L ong-Term Care Billing Manual, 15.8, p. 54 (Sept. 2023). (Accessed Jun. 2024).

Mental Health Rehabilitation Services Provider Certification Standards

Telemedicine/telehealth are included under reimbursable services. See rule for specific requirements.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3434. (Accessed Jun. 2024).

Mental Health Crisis/Emergency Services

A Crisis/Emergency Service is an immediate response face-to-face or via telehealth in accordance with 29 DCMR Â§ 910 to an emergency situation involving a consumer with mental illness or emotional disturbance that is available twenty-four (24) hours per day, seven (7) days per week.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3422. (Accessed Jun. 2024).

Clinical Care Coordination (CCC)

CCC may be rendered by a qualified practitioner pursuant to § 3432.8 practicing within the scope of their license in person or through telehealth in accordance with 29 DCMR § 910.

Qualified practitioners providing CCC shall:

Communicate treatment needs, assessments and treatment information to healthcare providers external to the consumer’s CSA or specialty provider;
Facilitate appropriate linkages for the consumer with other healthcare professionals external to the consumer’s CSA or specialty provider; and
Provide planning and Plan of Care implementation activities separate from the diagnostic assessment service when the clinician and consumer meet face-to-face or through telehealth pursuant to 29 DCMR § 910.

Providers must document CCC in an encounter note that meets the requirements of § 3413.19 and indicates the intended purpose of the service, the modality of communication, time spent reviewing or preparing records, the actions taken, and the result(s) achieved.

SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3432. (Accessed Jun. 2024).

Assertive Community Treatment (ACT)

During the calendar month billing cycle, the ACT provider must deliver at least five contacts face-to-face and may deliver up to three contacts via telehealth, including collateral contacts and the monthly MD/APRN contact. At least three contacts must be delivered by distinct qualified practitioners eligible to deliver ACT services pursuant to Title 22-A DCMR Chapter 34. See provider transmittals 23-39, 23-50, and 24-11 and rule for specific requirements.

SOURCE: DC Municipal Regulation, Title 29, Ch. 52, Sec. 5210.2 & Department of Health Care Finance, Notice of Final Rulemaking – Amending 29 DCMR Chapter 52 – Governing Assertive Community Treatment. Mar. 2024; Title 22, Chap. 22-A34, Sec. 3426, 3434, & Title 22, Chap. 22-A37, Sec. 3708, 3711 & Department of Behavioral Health – Notice of Final Rulemaking – Amending 22-A DCMR Ch. 34 and 37 – Assertive Community Treatment. Dec. 2023. (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

Telemedicine providers must comply with the following:

Be an enrolled Medicaid provider and comply with requirements including having a completed, signed Medicaid Provider Agreement
Comply with technical, programmatic and reporting requirements
Be licensed; and
Appropriately document the beneficiary’s written or verbal consent.
Comply with any other applicable consent requirements under District laws, including but not limited to Section 3026 of Title 5-E of the District of Columbia Municipal Regulations if providing telemedicine services at a District of Columbia Public School (DCPS) or District of Columbia Public Charter School (DCPCS).

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.6. (Accessed Jun. 2024)

D.C. Medicaid enrolled providers are eligible to deliver telemedicine services, using fee-for-service reimbursement, at the same rate as in-person consultations. All reimbursement rates for services delivered via telemedicine are consistent with the District’s Medical State Plan and implementing regulations.

The eligible distant site providers include but are not limited to the following:

Hospital
Nursing facility
Federally Qualified Health Center
Clinic
Physician Group/Office
Nurse Practitioner Group/Office
DCPS
DCPCS; and
MHRS provider, ASARS provider and ASTEP provider certified by DBH and eligible to provide behavioral health services set forth under the State Plan

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 3-4. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69, Outpatient Hospital Billing Guide, 15.8.3, p. 74-75 (Apr. 2024), Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2024), L ong-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023). (Accessed Jun. 2024).

At the discretion of the rendering provider, personnel delivering telemedicine services may work remotely, as long as all other requirements in the rule are met. See sections on technology, documentation in medical records, and confidentiality in guidance document for further specifications.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 3-4. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69, Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2024), L ong-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023) (Accessed Jun. 2024).

When a beneficiary’s home is the originating site, the distant site provider shall ensure the technology in use meets the minimum requirements.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.30. (Accessed Jun. 2024).

Federally Qualified Health Center (FQHC) Reimbursement

In accordance with the District’s Prospective Payment System (PPS) or alternative payment methodology (APM) for FQHCs, the following reimbursement parameters apply:

Originating Site: An FQHC provider must deliver an FQHC-eligible service in order to be reimbursed the appropriate PPS, APM, or fee-for-service (FFS) rate at the originating site;
Distant Site: An FQHC provider must deliver an FQHC-eligible service that is listed in Appendix A in order to be reimbursed the appropriate PPS, APM, or FFS rate; and
Originating and Distant Site: If both the originating and the distant site are FQHCs, for both to receive reimbursement, each site must deliver a different PPS or APM service (e.g. medical or behavioral). If both sites submit a claim for the same PPS or APM service (e.g. medical), then only the distance site will be eligible to receive reimbursement.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 4-5.,Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.5. P. 53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.5, P. 51. FQHC Billing Manual, DC Medicaid 15.5, P. 53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.5, p. 70. Inpatient Hospital Billing Guide, 11.5, p. 62 (Apr. 2024), Long-Term Care Billing Manual, 15.5, p. 53 (Sept. 2023) (Accessed Jun. 2024).

ELIGIBLE SITES

Eligible services can be delivered via telemedicine when the beneficiary is at the originating site, while the eligible “distant” provider renders services via the audio/video or audio-only connection.

When clinically indicated, an originating site provider or its designee shall be in attendance during the patient’s medical encounter with the distant site professional. An originating site provider shall not be required to be in attendance when the beneficiary prefers to be unaccompanied because the beneficiary feels the subject is sensitive. An originating site provider shall note their attendance status in the patient’s medical record.

To receive reimbursement, originating site providers must deliver an eligible service, distinct from the service delivered at the distant site, in order to receive reimbursement.

Telemedicine providers will submit claims in the same manner the provider uses for in person services.

When billing for services delivered via video-audio telemedicine, distant site providers shall enter the “GT” procedure modifier on the claim. When billing for any audio-only telemedicine services, distant site providers shall enter the “93” procedure modifier on the claim.

Additionally, the distant site provider must appropriately specify the place of service (POS) using the following POS codes:

In the event the beneficiary’s home is the originating site, the distant site provider must specify the place of service “10” which is defined as “telehealth provided in patient’s home”.
In the event a DCPS or a DCPCS is the originating site, the distant site provider must specific the place of service “03” which is defined as “school”.
In the event the beneficiary is at any other eligible originating site (see section IV above), the distant site provider must specify the place of service “02” which is defined as “telehealth provided other than in patient’s home”. When utilizing place of service “02”, the distant site provider must also report the National Provider Identifier (NPI) of the originating site provider in the “referring provider” portion of the claim.

Services billed where telemedicine is the mode of service delivery, but the claim form and/or service documentation do not indicate telemedicine (using the appropriate procedure modifiers and appropriate POS codes) are subject to disallowances in the course of an audit.

The Program will implement this telemedicine service for both providers and participants in the Medicaid fee-for-service, Medicaid managed care, Health Care Alliance, and Immigrant Children’s programs. All requirements stipulated in this provider guidance apply to all programs DHCF administers.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 1-4. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.4. P. 52-53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.4, P. 50-51. FQHC Billing Manual, DC Medicaid 15.4, P. 52-53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.4, p. 69-70, Inpatient Hospital Billing Guide, 11.4, p. 61-62 (Apr. 2024), Long-Term Care Billing Manual, 15.4, p. 52-53 (Sept. 2023) (Accessed Jun. 2024).

Effective March 1st, 2023, District health care providers rendering services to beneficiaries in Medicaid fee-for-service, Medicaid managed care, Health Care Alliance, and Immigrant Children’s programs must comply with these revised billing requirements. Refer to Transmittal #23-11 for additional information.

SOURCE: Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.4. P. 52-53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.4, P. 50-51. FQHC Billing Manual, DC Medicaid 15.4, P. 52-53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.4, p. 69-70, Inpatient Hospital Billing Guide, 11.4, p. 61-62 (Apr. 2024), Long-Term Care Billing Manual, 15.4, p. 52-53 (Sept. 2023) (Accessed Jun. 2024).

The beneficiary’s home, or other settings authorized by DHCF, may serve as the originating site. When the originating site is the beneficiary’s home the distant site provider is responsible for ensuring that the technology in use meets the minimum requirements set forth in Subsection 910.13.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7 & 910.30. (Accessed Jun. 2024).

POS 02 (telehealth) and POS 10 (telehealth provided in patient’s home) are listed as a valid place of service code in multiple DC Medicaid manuals.

SOURCE: DC Medicaid, Provider Specific Information, See each individual manual. (Accessed June 2024).

DHCF defines “the definition of “the beneficiary’s home or other settings” to include temporary lodging, such as hotels and homeless shelters. Additionally, for circumstances where the patient, for privacy or other personal reasons, chooses to travel a short distance from the exact home location during a telehealth service, the service is still considered to be furnished” in the home of an individual.

SOURCE: Department of Health Care Finance. Telemedicine Provider Guidance Clarification “Beneficiary’s Home or Other Settings”. March 2023. (Accessed Jun. 2024).

Must be an approved telemedicine provider. The following providers are considered an eligible originating site:

Hospital
Nursing facility
Federally Qualified Health Center
Clinic
Physician Group/Office
Nurse Practitioner Group/Office
District of Columbia Public Schools (DCPS)
District of Columbia Public Charter Schools (DCPCS)
Mental Health Rehabilitation Service (MHRS) provider, Adult Substance Abuse Rehabilitation Service (ASARS) provider, and Adolescent Substance Abuse Treatment Expansion Program (ASTEP) provider certified by the Department of Behavioral Health (DBH) and eligible to provide behavioral health services set forth under the District of Columbia Medicaid State Plan (State Plan).
The beneficiary’s home or other settings identified in guidance published on the DHCF website.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7, Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 2-3. Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.3, p. 69. Outpatient Hospital Billing Guide, 15.8.3, p. 74 (Apr. 2024), Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2024), Long-Term Care Billing Manual, 15.3, p. 52 (Sept. 2023). (Accessed Jun. 2024).

When a beneficiary’s home is the originating site, the distant site provider shall ensure the technology in use meets the minimum requirements set forth in Subsection 910.13.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 7. (Accessed Jun. 2024).

When DCPS or DCPCS is the originating site provider, a primary support professional (an individual designated by the school) shall be in attendance during the patient’s medical encounter.

An originating site provider shall not be required to be in attendance when the beneficiary prefers to be unaccompanied because the beneficiary feels the subject is sensitive. Sensitive topics may include counseling related to abuse, or other psychiatric matters. An originating site provider shall note their attendance status in the patient’s medical record.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.16-17. (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

No transaction or facility fee.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.28, Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6, Physicians Billing Manual. DC Medicaid. (Jan. 2024) Sec. 15.8. P. 54, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.8, P. 52. FQHC Billing Manual, DC Medicaid 15.6.2, P. 54. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.8, p. 71, Outpatient Hospital Billing Guide, 15.8.6, p. 75 (Apr. 2024), Inpatient Hospital Billing Guide, 11.8, p. 63 (Apr. 2024), L ong-Term Care Billing Manual, 15.8, p. 54 (Sept. 2023). (Accessed Jun. 2024).

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Florida

Last updated 06/11/2024

POLICY

During the federal PHE, the Agency provided expansive coverage …

POLICY

During the federal PHE, the Agency provided expansive coverage for telemedicine services. Effective May 11, 2023, Florida Medicaid will cover telehealth services in accordance with the Agency’s promulgated Telemedicine rule and will no longer cover audio-only telehealth services. Florida Medicaid will continue to cover store-and-forward and remote patient monitoring services.

As a reminder, Statewide Medicaid Managed Care (SMMC) plans may provide more expansive coverage than what is in Agency rule, including telemedicine and waiving co-payments. However, SMMC plans may not be more restrictive than Agency rule.

SOURCE: FL Medicaid, Alert, Ending of Federal Public Health Emergency: Updated Co-Payment and Telemedicine Guidance for Medical and Behavioral Health Providers, May 4, 2023, (Accessed Jun. 2024).

FL Medicaid reimburses for real time, two-way, interactive telemedicine.

Providers must include the GT modifier.

SOURCE: FL Admin Code 59G-1.057. (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

List of eligible community behavioral health services is provided in Provider Alert. See alert for procedure codes, modifiers and telemedicine modifiers.

SOURCE: FL Medicaid, Alert, Community Behavioral Health Telemedicine-Eligible Services, May 12, 2023, (Accessed Jun. 2024).

Florida Medicaid reimburses the practitioner who is providing the evaluation, diagnosis, or treatment recommendation located at a site other than where the recipient is located.

SOURCE: FL Admin Code 59G-1.057. (Accessed Jun. 2024).

Behavioral Analysis

The Lead Analyst may provide up to two hours per week of training to parents or guardians via telemedicine in accordance with Rule 59G-1.057, Florida Administrative Code (F.A.C.).

SOURCE: FL Medicaid, Behavior Analysis Services Coverage Policy, Sept. 2023, (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

Telemedicine is available for use by all providers of Florida Medicaid services that are enrolled in or registered with the Florida Medicaid program and who are licensed within their scope of practice to perform the service.

SOURCE: FL Admin Code 59G-1.057. (Accessed Jun. 2024).

ELIGIBLE SITES

No Reference Found

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

No Reference Found

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Georgia

Last updated 05/20/2024

POLICY

The use of a telecommunications system may substitute for …

POLICY

The use of a telecommunications system may substitute for an in-person encounter for professional office visits, pharmacologic management, limited office psychiatric services, limited radiological services and a limited number of other physician fee schedule services. See the telehealth guidelines for program specific policies.

SOURCE: GA Dept. of Community Health, Physician Services Manual, p. 168 (Apr. 1, 2024). (Accessed May. 2024).

Medicaid covered services are provided via telehealth for eligible members when the service is medically necessary, the procedure is individualized, specific, and consistent with symptoms or confirmed diagnosis of an illness or injury under treatment, and not in excess of the member’s needs.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 5 (Apr. 1, 2024). (Accessed May 2024).

ELIGIBLE SERVICES/SPECIALTIES

An interactive telecommunications system is required as a condition of payment. The originating site’s system, at a minimum, must have the capability of allowing the distant site provider to visually examine the patient’s entire body including body orifices (such as ear canals, nose and throat). The distant site provider should also have the capability to hear heart tones and lung sounds clearly (using a stethoscope) if medically necessary and currently within the provider’s scope of practice. The telecommunication system must be secure and adequate to protect the confidentiality and integrity of the information transmitted.

SOURCE: GA Dept. of Community Health, Physician Services Manual, p. 168 (Apr. 1, 2024). (Accessed May. 2024).

Claims for telehealth services must use the appropriate CPT or HCPCS code for the professional service. The GT modifier is required as applicable, and/or the use of either POS 02 or POS 10. POS 02 will indicate Telehealth services that were utilized at a location other than at the patient’s home. The GQ modifier is still required as applicable. By coding and billing with the covered telehealth procedure code, providers are certifying that the member was present at an eligible originating site when you furnished the telehealth service. CPT modifier ‘‘93’’ can be appended to claim lines, as appropriate, for services furnished using audio only communications technology. Interactive audio and video telecommunications must be used, permitting real time communications between the distant site provider or practitioner and the member.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 8, 10 (Apr. 1, 2024). (Accessed May. 2024).

Physician Services: When an enrolled provider determines that medical care can be provided via electronic communication with no loss in the quality or efficacy of the member’s care, telehealth services can be performed.

An interactive telecommunications system is required as a condition of payment. The originating site’s system, at a minimum, must have the capability of allowing the distant site provider to visually examine the patient’s entire body including body orifices (such as ear canals, nose, and throat). Depending upon an enrolled provider’s specialty and scope of practice, the distant provider should also have the capability to hear heart tones and lung sounds clearly (using stethoscope) if medically necessary and currently within the provider’s scope of practice. The telecommunication system must be secure and adequate to protect the confidentiality and integrity of the information transmitted.

Providers may not bill for services or charge a fee for missed appointments. Cost associated with the
use of technology or data transmission are not covered under Medicaid and cannot be charged to the
member.

See telehealth manual for list of eligible telehealth services and codes for specific programs.

Non-Covered Service Modalities:

Telephone conversations.
Electronic mail messages.
Facsimile.
Services rendered via a webcam or internet-based technologies (i.e., Skype, Tango, etc.) that are not part of a secured network and do not meet HIPAA encryption compliance.
Video cell phone interactions.
The cost of telehealth equipment and transmission.
Failed or unsuccessful transmissions.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance, p. 5, 8, 10 (Apr. 1, 2024). (Accessed May 2024).

Nursing Facilities

Though not available in all areas of the State, Medicare-funded mental health services are currently provided to nursing home residents via telehealth (telemedicine), face-to-face visits by providers in the nursing home, and nursing home resident visits to psychiatric/mental health clinics/offices for those individuals able to travel outside the nursing facility. See manual for codes.

Those residents whose interest is best served by receiving mental health services in the nursing
facility or in a nearby telemedicine site can receive services in either of those locations, with the
practitioner using out-of-clinic or telemedicine procedure codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 23-25 (Apr. 1, 2024) & GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Nursing Facility Services, p. H-1 , H-7 (p. 145, 151). (Apr. 1, 2024). (Accessed May 2024).

Teledentistry

See dental services manual for teledentistry codes.

SOURCE: GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Dental Services, IX-21, p. 60 (Apr. 2024). GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 19 (Apr. 1, 2024). (Accessed May 2024).

GT modifier to be used in conjunction with the appropriate codes for Telemedicine following full
implementation of HIPAA compliance (see “Telemedicine Consultations.”).

SOURCE: GA Dept. of Community Health, Division of Medical Assistance, Part II: Policies and Procedures: Oral Maxillofacial Surgery Services (April 2024), p. G-2. (Accessed May. 2024).

Autism Spectrum Disorder Services

Practitioners of Autism Spectrum Disorder (ASD) services can use telehbehavioealth to assess, diagnose and provide therapies to patients. Prior authorization is required for all Medicaid-covered adaptive behavior services, behavioral assessment and treatment services (not telehealth specific). See manual for eligible codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 13 (Apr. 1, 2024). (Accessed May 2024).

Community Behavioral Health and Rehabilitation Services (CBHRS)

The Departments of Community Health and Behavioral Health and Developmental Disabilities have authorized telemedicine to be used to provide some services in the CBHRS program. See Behavioral Health and Development Disabilities manual for more detailed information.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 17-19 (Apr. 1, 2024). GA Department of Community Health for CBHRS, p. 99-101 (Apr. 1, 2024). GA Dept. of Behavioral Health & Developmental Disabilties, Provider Manual for Community Behavioral Health Providers (Mar 1. 2023). (Accessed May 2024).

Those residents whose interest is best served by receiving mental health services in the nursing facility or in a nearby telemedicine site can receive services in either of those locations, with the practitioner using out-of-clinic or telehealth/telemedicine procedure codes.

SOURCE: GA Dept. of Community Health, Division of Medical Assistance, Part II Policies and Procedures for Community Behavioral Health Rehabilitation Services, p. 69, (Apr. 1, 2024). (Accessed May 2024).

Dialysis Services

The Centers for Medicaid and Medicare Services (CMS) has added Dialysis Services to the list of services that can be provided under Telehealth. The distant site/physician providing the service via a telecommunications
system will bill using Place of Service 02 to indicate Telehealth.See manual for list of eligible CPT codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 17-18 (Apr. 1, 2024). (Accessed May. 2024).

School Based Services

Telehealth benefits are allowed if all the following criteria are met:

The provider is an authorized health-care provider enrolled in Georgia Medicaid
The client is a child who is receiving the service in a primary or secondary school-based setting
The parent or legal guardian of the client provides consent before the service is provided.

Speech Language Pathology Services involve the identification of children with speech and/or language disorders, diagnosis and appraisal of specific speech and/or language disorders, referral for medical and other professional attention necessary for the rehabilitation of speech and/or language disorders, provision of speech or language services for the prevention of communicative disorders. The speech language pathologist must bill for time spent in hands on activities or via telehealth services with the student. This includes time spent assisting the student with learning to use adaptive equipment and assistive technology.

See manual for eligible CPT/HCPCS speech, audiology and physical therapy codes.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 26-27 (Apr. 1, 2024). (Accessed May. 2024).

The rendering provider serving as the telemedicine distant site should report the E/M office visit code (992xx) along with the GT modifier (including any other applicable modifiers), the appropriate POS, and the ICD-10 diagnosis code(s). See manual for more details.

SOURCE: GA Dept. of Community Health, EPSDT Health Check Program , p. 68 (Apr. 2024). (Accessed May 2024).

Durable Medical Equipment Services

A face-to-face encounter may be made through the use of telehealth technology by reporting the appropriate E&M code.

SOURCE: GA Dept. of Community Health, GA Medicaid Durable Medical Equipment Services Manual, p. 34 (Apr. 1, 2024). (Accessed May 2024).

Elderly and Disabled Waiver EDWP Traditional/Enhanced Case Management

Members must be seen by their PCP annually, either in the office of the PCP or via Telehealth with the SNS provider RN performing the call.

SOURCE: GA Dept of Community Health, Division of Medicaid, Policies and Procedures for Elderly and Disabled Waiver EDWP – (CCSP) Traditional/Enhanced Case Management (Apr. 1, 2024), p. 23. (Accessed May 2024).

EDWP (CCSP and Source) Skilled Nursing Services by Private Home Care Providers

Registered Nurse Responsibilities include facilitating telehealth visits with the member and the member’s PCP.

SOURCE: GA Dept of Community Health, Division of Medicaid, Policies and Procedures for EDWP (CCSP and SOURCE): General Services (Apr.1, 2024), p. 211-212; Skilled Nursing Services by Private Home Care Providers (Apr. 1, 2024), p. 7, 11-12.; (Accessed May 2024).

Department of Community Health

The Department of Community Health (DCH) will allow medically necessary services to be rendered via telehealth. Each billed procedure code must be submitted with the usual program modifier(s). Place of service code 02 must be added to the allowed procedure codes to indicate the services are related to telehealth services.

SOURCE: GA Dept of Community Health: Early Intervention Case Management Program, p. 25 (Apr. 1, 2024). (Accessed May. 2024).

Children’s Intervention Services

The Department of Community Health will allow some speech therapy, therapy and audiology services to be rendered via telehealth. See manual for appropriate codes.

SOURCE: GA Dept. of Community Health, Division of Medicaid, Children’s Intervention Services (Apr. 1, 2024), p. 47. GA Dept. of CommunityHealth, Childrens Intervention School Services (Apr. 1, 2024), p. 39-40. (Accessed May 2024).

Comprehensive Supports Waiver Program (COMP)

All components of Adult Occupational Therapy, Adult Physical Therapy, Speech and Language Therapy, Adult Nutrition Services, Interpreter Services can be safely provided via telehealth modalities according to prevailing best practice standards published by the American Speech and Language Hearing (Occupational or Physical Therapy) Association and in accordance with the Georgia license requirements under O.C.G.A. § 43-44-7. Therapists are expected to use synchronous “in real time” audio/video technology for telehealth sessions. Telephone calls and store and forward (asynchronous) modalities are not allowed for billable therapy evaluation and services.

Payment is not made for feeding and swallowing evaluation and treatment via any telehealth modality. (Adult Speech and Language).

Some components of Behavior Supports Services can be provided via a telehealth modality to supplement in-person service delivery. The following components are the only components that are allowable for a telehealth option:

Indirect assessment component for functional behavior assessment;
Follow up or refresher staff training for behavior support plans;
Additional fidelity monitoring of plan implementation and oversight;
Distant site observations of the individual for the purposes of consultation, modeling, and recommendations for interventions to staff/caregivers in real time;
Team meetings for the purpose of gathering feedback related to behavior support plans effectiveness; and
Review of data analysis summaries and behavior graphing.

See manual for more details.

SOURCE: GA Dept. of Community Health, Comprehensive Supports Waivers Program (COMP) Chapters 1300-3700 (Apr. 1, 2024), GA Dept. of CommunityHealth, New Options Waiver Program (NOW) (Apr. 1, 2024). (Accessed May 2024).

Independent Care Waiver Services

Counseling and Behavioral Management services are available to members needing treatment for personal, social or behavioral disorders to maintain and improve effective functioning. Counseling services can be provided via telehealth with or without a visual component.

SOURCE: GA Dept. of Community Health, Independent Care Waiver Services (Apr. 1, 2024), p. 87 & 92. (Accessed May. 2024).

ELIGIBLE PROVIDERS

The consulting provider must be an enrolled provider in Medicaid in the state of Georgia and must document all findings and recommendations in writing, in the format normally used for recording services in the member’s medical records. The provider at the distant site must obtain prior approval when services require prior approval. Both the originating site and distant site must document and maintain the member’s medical records. The report from the distant site provider may be faxed to the originating provider.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 9 (Apr. 1, 2024). (Accessed May. 2024).

Autism Spectrum Disorder Services

Practitioners of ASD services can use telehealth to assess, diagnose and provide therapies to patients. Providers must hold either a current and valid license to practice Medicine in Georgia, hold a current and valid license as a Psychologist as required under Georgia Code Chapter 39 as amended, or hold a current and valid Applied Behavior Analysis (ABA) Certification. In addition to licensed Medicaid enrolled Physicians and Psychologists, Georgia Medicaid will enroll Board Certified Behavioral Analysts (BCBAs) as Qualified Health Care Professionals (QHCPs) to provide ASD treatment services. The BCBA must have a graduate-level certification in behavior analysis. Providers who are certified at the BCBA level are independent practitioners who provide behavior-analytic services. In addition, BCBAs supervise the work of Board-Certified Assistant Behavior Analysts (BCaBAs), and Registered Behavior Technicians (RBTs) who implement behavior-analytic interventions.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 13 (Apr. 1, 2024). (Accessed May 2024).

Community Behavioral Health and Rehabilitation Services

See manual for eligible practitioner types and levels for CBHRS.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 19 (Apr. 1, 2024). (Accessed May 2024).

Teledentistry

Licensed dentists and dental hygienists are eligible providers.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 19 (Apr. 1, 2024). (Accessed May 2024).

Federally Qualified Health Center (FQHC)/Rural Health Center (RHC)

FQHCs and RHCs can serve as the originating or distant site. They cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 20 (Apr. 1, 2024) & GA Dept. of Community Health, Policies and Procedures for Federally Qualified Health Center Services and Rural Health Clinic Services, p. 30, (Apr. 1, 2024). (Accessed May 2024).

Nursing Facility Specialized Services

See manual for eligible providers and levels.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 23 (Apr. 1, 2024). (Accessed May. 2024).

Advanced Nurse Practitioner & Nurse Midwifery Services

GT modifier must be used in conjunction with the appropriate codes for Telemedicine following full implementation of HIPAA compliance (see “Telemedicine Consultations.”).

SOURCE: GA Dept. of Community Health, GA Medicaid Division, Advanced Nurse Practitioner Services (Apr 16, 2024), p. 24. GA Dept. of Community Health, GA Medicaid Division, Nurse Midwifery Services, p. 36 (Apr, 16, 2024). (Accessed May 2024).

School-Based Settings (Local Education Agencies)

Telehealth services are allowed in school-based settings upon enrollment into COS 600. The following requirements must be met:

The provider is an authorized health-care provider enrolled in Georgia Medicaid
The client is a child who is receiving the service in a primary or secondary school-based setting
The parent or legal guardian of the client provides consent before the service is provided

Telehealth services provided in a school-based setting are also a benefit if the referring provider delegates provision of services to a nurse practitioner, clinical nurse specialist, physician assistant, or other licensed specialist as long as the above-mentioned providers are working within the scope of their professional license and within the scope of their delegation agreement with the provider.

The school must enroll as a Health Check Provider in order to bill the telehealth originating site facility fee.

LEAs must submit an Attestation Form for the provision of telehealth services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 26 (Apr. 1, 2024).(Accessed May 2024).

ELIGIBLE SITES

Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014 with a payment of $20.52. Hospitals are eligible to receive reimbursement for a facility fee for telehealth when operating as the originating site. Claims must be submitted with revenue code 780 (telehealth) and type of bill 131. There is no separate reimbursement for telehealth serves when performed during an inpatient stay, outpatient clinic or emergency room visit or outpatient surgery, as these are all-inclusive payments.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 8 (Apr. 1, 2024). (Accessed May 2024).

Ambulance Providers

They may serve as originating sites and the ambulance may bill a separate origination site fee. They are not authorized to provide distant site services.

Limitation (Emergency Ambulance Services Handbook): Emergency ambulance services are reimbursable only when medically necessary. The recipient’s physical condition must prohibit use of any method of transportation except emergency for a trip to be covered. See Emergency Ambulance Handbook for more specific information.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 12 (Apr. 1, 2024). & Emergency Ambulance Services Handbook, p. 17-18 (Apr. 1, 2024). (Accessed May 2024).

Community Behavioral Health and Rehabilitation Services

Member may be located at home, schools and other community-based settings or at traditional sites named in the Department of Community Health Telehealth Guidance. See manual for detailed instructions explanation for when and which type of practitioner can bill for telehealth services.

Traditional sites include:

Physician and Practitioner’s Offices;
Hospitals;
Rural Health Clinics;
Federally Qualified Health Centers;
Local Education Authorities and School Based Clinics;
County Boards of Health;
Emergency Medical Services Ambulances; and
Pharmacies.

SOURCE: GA Dept. of Community Health, Community Behavioral Health Rehabilitation Services Handbook Appendix O, p.99 (Apr. 1, 2024). GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 18 (Apr. 1, 2024). (Accessed May 2024).

Teledentistry

D9996 is the originating site fee…D9996 is used by the Dental Hygienist when dental information is sent to a licensed Dentist for review via telemedicine technology. The Dentist that does the requested exam then bills the Department D0140 for the exam and report.

Services can now be provided in Federally Qualified Health Centers, volunteer community health settings, senior centers and family violence shelters.

SOURCE: GA Dept. of Community Health, Polices & Procedures II: Dental Services p. 60 (Apr. 1, 2024). (Accessed May 2024).

Federally Qualified Health Center (FQHC)/Rural Health Center (RHC)

FQHCs and RHCs can serve as originating sites and are paid an originating site facility fee. They cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 20 (Apr. 1, 2024). & GA Dept. of Community Health, Policies and Procedures for Federally Qualified Health Center Services and Rural Health Clinic Services, p. 23, (Apr. 1, 2024). (Accessed May 2024).

Dialysis Services

Dialysis facilities are eligible originating sites for dialysis services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 20 (Apr. 1, 2024). & GA Dept. of Community Health, GA Medicaid Dialysis Services Handbook, p. 17 (IX-10). (Apr. 1, 2024) (Accessed May 2024).

Nursing Facility Specialized Services

Nursing facilities can be eligible sites for nursing facility specialized services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 23 (Apr. 1, 2024). & GA Dept. of Community Health, Nursing Facility Services, p. H-7 (p. 151). (Apr. 1, 2024). (Accessed May 2024).

School-Based Settings (Local Education Agencies)

Telehealth services are allowed in school-based settings upon enrollment into COS 600. The following requirements must be met:

The provider is an authorized health-care provider enrolled in Georgia Medicaid
The client is a child who is receiving the service in a primary or secondary school-based setting
The parent or legal guardian of the client provides consent before the service is provided

The school must enroll as a Health Check Provider in order to bill the telehealth originating site facility fee.

LEAs must submit an Attestation Form for the provision of telehealth services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 26 (Apr. 1, 2024)., GA Dept. of CommunityHealth, Childrens Intervention School Services (Apr. 1, 2024), p. 9. (Accessed May 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Cost associated with theuse of technology or data transmission are not covered under Medicaid and cannot be charged to the member.

Originating sites are paid an originating site facility fee. Hospitals are eligible to receive reimbursement for a facility fee for telehealth when operating as the originating site. There is no separate reimbursement for telehealth serves when performed during an inpatient stay, outpatient clinic or emergency room visit or outpatient surgery, as these are all-inclusive payments.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 8 (Apr. 1, 2024). (Accessed May 2024).

Community Behavioral Health and Rehabilitation Services

Originating fees (as referenced in some of the other Georgia Medicaid programs) are not offered for telemedicine when utilized in the CBHRS category of service. Telemedicine costs are attributed to the services intervention rates.

SOURCE: GA Dept. of Community Health: Community Behavioral Health and Rehabilitation Services, p. 100 (Apr. 1, 2024), GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 18 (Apr. 1, 2024). (Accessed May 2024).

School-Based Settings (Local Education Agencies)

LEAs that enroll as Health Check providers to serve as telehealth originating sites only will be allowed to bill the originating site facility fee. The telehealth originating facility fee is reimbursed at the current DEFAULT rate.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 26 (Apr. 1, 2024). & GA Dept. of Community Health, Children’s Intervention Services, p. 47 (Apr. 1, 2024) GA Dept. of CommunityHealth, Childrens Intervention School Services (Apr. 1, 2024), p. 9. (Accessed May 2024).

Ambulance Providers

Ambulances may bill a separate origination site fee. The Telehealth originating fee (Q3014) cannot be billed in combination with other rendered EMS services.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 21 (Jan. 1, 2024). & Emergency Ambulance Services Handbook p. 17 (Jan. 1, 2024). (Accessed Jan 2024).

Dialysis Services

The originating facility/site (Dialysis Facility) will bill with the revenue code and procedure codes listed in the manual.

SOURCE: GA Dept. of Community Health, GA Medicaid Telemedicine Guidance Handbook, p. 12 (Apr. 1, 2024). & GA Dept. of Community Health, GA Medicaid Dialysis Services Handbook, p. IX-10 (17) (Apr. 1, 2024). (Accessed Apr 2024).

FQHC/RHC

FQHCs and RHCs that serve as an originating site for telehealth services are paid an originating site facility fee.

FQHCs and RHCs cannot bill an originating site fee and distant site fee for telehealth services on the same encounter.

SOURCE: GA Dept. of Community Health, GA Medicaid Telehealth Guidance Handbook, p. 20 (Apr. 1, 2024). GA Dept. of Community Health, GA Medicaid Federally Qualified Health Centers and Rural Health Clinics (Apr. 1, 2024), p. 23. (Accessed May 2024).

EPSDT Services – Health Check Program

LEAs enrolled as Health Check providers to serve as telemedicine originating sites only will be allowed to bill the telemedicine originating site facility fee (procedure code Q3014).

SOURCE: GA Dept. of Community Health, EPSDT Services – Health Check Program, p. 68 (X-7). (Apr. 1, 2024). (Accessed May 2024).

Children’s Intervention Services

Originating sites are paid an originating site facility fee for telehealth services by billing procedure code Q3014.

SOURCE: GA Dept. of Community Health, Division of Medicaid, Children’s Intervention Services (Apr. 1, 2024), p. 47. (Accessed Apr. 2024).

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Hawaii

Last updated 06/03/2024

POLICY

The State’s Medicaid managed care and fee-for-service programs shall …

POLICY

The State’s Medicaid managed care and fee-for-service programs shall not deny coverage for any service provided through telehealth that would be covered if the service were provided through in-person consultation between a patient and a health care provider.

(Repeal and reenactment on December 31, 2025) Reimbursement for services provided through telehealth via an interactive telecommunications system shall be equivalent to reimbursement for the same services provided via in-person contact between a health care provider and a patient; provided that reimbursement for the diagnosis, evaluation, or treatment of a mental health disorder delivered through an interactive telecommunications system using two-way, real-time audio-only communication technology shall meet the requirements of title 42 Code of Federal Regulations section 410.78. Nothing in this section shall require a health care provider to be physically present with the patient at an originating site unless a health care provider at the distant site deems it necessary.

SOURCE: HI Revised Statutes § 346-59.1 (a & b). Amended by HB 907 HD2 SD 2 (Repeal date of December 31, 2025). (Accessed Jun. 2024).

Reimbursement for services provided through telehealth via an interactive telecommunications system shall be equivalent to reimbursement for the same services provided via in-person contact between a health care provider and a patient; provided that reimbursement for two-way, real-time audio-only communication technology for purposes of diagnosis, evaluation, or treatment of a mental health disorder to a patient in the patient’s home shall be equivalent to eighty per cent of the reimbursement for the same services provided via in-person contact between a health care provider and a patient.

To be reimbursed for telehealth via an interactive telecommunications system using two-way, real-time audio-only communication technology in accordance with this subsection, the health care provider shall first conduct an in-person visit or a telehealth visit that is not audio only, within six months prior to the initial audio-only visit, or within twelve months prior to any subsequent audio-only visit. The telehealth visit required prior to the initial or subsequent audio-only visit in this subsection shall not be provided using audio-only communication. Nothing in this section shall require a health care provider to be physically present with the patient at an originating site unless a health care provider at the distant site deems it necessary.

SOURCE: HI Revised Statutes § 431:10A-116.3(c). Amended by HB 907 HD2 SD 2 (Repeal date of December 31, 2025). (Accessed Jun 2024).

Interactive audio and video telecommunication systems must be used. Interactive telecommunications systems must be multi-media communications that, at a minimum, include audio and video equipment, permitting real-time consultation among the patient, consulting practitioner, and referring practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the requirements of interactive telecommunications system. As a condition of payment the patient must be present and participating in the telehealth visit.

SOURCE: Code of HI Rules 17-1737-51.1(c). (Accessed Jun. 2024). (NOTE: Recent legislation not yet reflected in Rules)

Eligible providers are health care providers who are eligible to bill Hawai’i Medicaid; practicing within their scope; and delivering services which can be appropriately and effectively administered through telehealth.

Services provided by telehealth must be appropriate for the telehealth modality, clinically appropriate for the patient, rendered in conformance with the full description of the procedure code, and performed by a health care provider eligible to bill Hawai’i Medicaid. Services provided shall be consistent with all federal and state privacy, security, and confidentiality laws.

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QIk-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

As noted in the Overview, due to the Maui fires, a public health emergency (PHE) was declared on August 8, 2023. Certain waivers were put into place for telehealth policies. See Med-Quest Memo QI-2335A for more information.

ELIGIBLE SERVICES/SPECIALTIES

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Dentistry

The eligible codes for reimbursement will remain consistent with Memo QI-1702A (see Attachment A) with the addition of code D0145. All eligible codes are subject to the processing policies as defined in Chapter 14 of the Medicaid Dental Provider Manual. See Manual also for codes.

CDT code D9999 must be used to identify the claim for PPS payment by FQHCs and RHCs.

While the reimbursement for radiographic services is traditionally based on the date that the radiograph is read by the dentist providing the diagnosis, to minimize confusion that may potentially arise with asynchronous technology, the following protocol will be used when filing claims:

Only one claim submission is allowed for each patient visit. All services to be claimed must be included in that single submission.
The service date on the claim is the date that the patient was treated at the originating site regardless of whether asynchronous or synchronous technology was used.
When asynchronous technology is used and the service date on the claim does not match the clinical notes (interpretation of the x-rays was done on a different day from when the patient was seen), a notation in clinical records should explain the discrepancy for auditing purposes.

The FFS reimbursement fee is based on the location of the eligible Medicaid provider at the time of service, Oahu or Neighboring Island.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 37-38 (Apr. 2024). HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Applied Behavioral Analysis & Autism Spectrum Disorder

Applied behavioral analysis services (including family adaptive behavior treatment guidance) can be provided through telehealth. MedQuest provides some areas of consideration when approving ABA services through telehealth (see memo). Memo QI 2301/FFS 23-01 Updates policy.

SOURCE: QI-2020 (Jun. 17, 2020), HI Med-Quest memo QI-2301/FFS 23-01.(January 13, 2023) (Accessed Jun. 2024).

Federally Qualified Health Centers

Providers who are eligible to bill for Hawaii Medicaid services are also eligible providers who can bill for telehealth. Eligible services will be consistent with Memo QI-1702A and FFS 19-01. See memo for specific billing scenarios. Memo QI- 2139/FFS 21-15 replaces Memo QI-1702A. See Attachment C in QI-2338/FFS 23-22, CCS-2311.

SOURCE: Med-QUEST Memo 20-07 (Mar. 16, 2020), QI-2139 Tele-Health Law (Act 226, SLH 2016) Implementation (Replaces QI-1702A) HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Community Integration Services (CIS)-Supportive Housing Services

CIS services may be rendered via telehealth as appropriate, as long as the required face-to-face interaction requirements are met (See Section 16, Service Settings for more information). Services rendered via telehealth shall be billed with the additional and appropriate telehealth modifiers, and applicable POS codes, as outline in memorandum QI-1702A (NOTE: QI 1702A was replaced with QI-2338/FFS 23-22/CCS 2311). Services may also be rendered via an approved telehealth modality, if determined by the health plan to be appropriate and effective and agreed to by the member.

SOURCE: Med-QUEST Memo QI-2105 (April 1, 2021). (Accessed Jun. 2024).

Induced/Intentional Termination of Pregnancy (ITOP) Evaluation & Management Services

Telehealth (audio-visual modality) may be used for evaluation and management services performed prior to the date of the medical ITOP. Codes in the range of 99201-99215 with modifiers 95, GQ, or GT are allowed.

SOURCE: Med-QUEST Memo FFS 2105 (May 7, 2021). (Accessed Jun. 2024).

QUEST Integration Health Plans & Community Case Management Agencies

Assessments and re-assessments may be conducted using telehealth and telecommunications technology only if an in-person interaction is not an option and should only be used on an exception basis. In-person interactions with members using appropriate safety precautions is the current expectation. Where possible, members at greatest risk and need should be prioritized to receive in-person interactions before members at lower risk and need.

The health plan must document the reason for conducting an interaction using a technology option.

SOURCE: Memo QI-2107A (April 29, 2021). (Accessed Jun. 2024).

Chronic Hepatitis C Infection

An in-person or telehealth/phone visit may be scheduled, if needed, for patient support, assessment of symptoms, and/or new medications.

SOURCE: HI Med-Quest Memo QI-2227/FFS 22-08 (December 30, 2022). (Accessed Jun. 2024).

Health and Functional Assessments

The assessment should include a face-to-face interview. Assessments and reassessments may be conducted by telehealth, based on member’s choice and preference. If using telehealth, it must meet privacy requirements.

SOURCE: HI Med-Quest Memo QI-2406, (Feb. 28, 2024), pg. 49, (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Dentistry

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 38 (Apr. 2024) (Accessed Jun. 2024).

Federally Qualified Health Centers

Providers who are eligible to bill for Hawaii Medicaid services are also eligible to bill for telehealth. Refer to HRS §346-53.64 (5) for the list of providers who may provide PPS services. See Attachment C in QI-2338/FFS 23-22, CCS-2311.

SOURCE: Med-QUEST FFS Memo 20-03 (Mar. 16, 2020), HI Med-QUEST Medicaid Provider Manual: Federally Qualified Health Centers, Chapter 21 (21.2.1),pg. 2 , HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

ELIGIBLE SITES

All providers prescribing controlled substances must be located in the State of Hawai’i. Until December 31, 2024, Federally Qualified Health Center (FQHC) behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories. If the FQHC provider is prescribing controlled substances, they must be located in the State of Hawai’i.

Originating/Spoke Site – The location where the patient is located, whether accompanied or not by a health care provider, at the time services are provided by a health care provider through telehealth, including but not limited to a health care provider’s office, hospital, critical access hospital, rural health clinic, federally qualified health center, a patient’s home, and other nonmedical environments such as school-based health centers, university-based health centers, or the work location of the patient. The originating site includes a patient’s residence. The U.S. Department of Health and Human Services Office for Civil Rights expects that patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances.

Distant/Hub Site – The location of the enrolled Hawai’i Medicaid provider delivering Medicaid eligible services through telehealth. The U.S. Department of Health and Human Services Office for Civil Rights expects health care providers will implement HIPAA safeguards and conduct telehealth in private settings, such as a doctor in a clinic or office connecting to a patient who is at home or at another clinic.

Non-FQHC Providers

With one exception, the provider must be located within the United States and the United States’ territories is eligible to be a distant site for delivery and payment purposes. Exception: If prescribing controlled substances, the provider must be located in the State of Hawai’i.

FQHC Providers

With exceptions, the FQHC provider must be located at their contracted FQHC’s HRSA approved site or satellite.

Exceptions:

Until December 31, 2024, FQHC behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories.
If prescribing controlled substances, the provider must be located in the State of Hawai’i.

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Eligible originating sites listed in the Administrative Rules:

The office of a physician or practitioner
Hospitals;
Critical Access Hospitals;
Rural Health Clinics;
Federally Qualified Health Centers;
Federal telehealth demonstration project sites.

SOURCE: Code of HI Rules 17-1737-51.1(d), p. 70 – Law passed & state plan amendment accepted prohibiting this limitation, however the prohibiting language is still present in regulation (Accessed Jun. 2024).

In statute, these locations are also included:

A patient’s home;
Other non-medical environments such as school-based health centers, university-based health centers, or the work location of a patient.

SOURCE: HI Revised Statutes § 346-59.1. (Accessed Jun. 2024).

Approved state plan amendment authorizes HI Medicaid to remove geographic and originating site requirements.

SOURCE: HI State Plan Amendment 16-0004. (Accessed Jun. 2024).

Federally Qualified Health Centers:

The criteria for sites eligible to receive PPS payment is the same regardless whether or not tele-health is utilized. The services must be provided at an HRSA approved site or satellite. 5C (Other Activities/Locations) sites are not eligible to receive PPS reimbursement in Hawaii and therefore are not eligible to receive PPS for tele-health services.

The spoke (originating site) is the location where the patient is located whether accompanied or not by a health care provider through telehealth. The originating site includes a patient’s residence.

SOURCE: HI Med-QUEST FFS Memo 20-03. (Accessed Jun. 2024).

Dental

The Medicaid rules for claims for teledentistry-related services will be consistent with the State’s rules on where teledentistry may be used.

The FFS reimbursement fee is based on the location of the eligible Medicaid provider at the time of service, Oahu or Neighboring Island.

Clinics that qualify for FQHC Prospective Payment System (PPS) reimbursement may submit telehealth claims using PPS reimbursement, as long as both the patient and dentist were each physically located at separate eligible FQHC/RHC sites during the encounter and the diagnosis. (Form 5b service sites registered with Med-QUEST as a Medicaid location and issued a HRSA Notice of Award identifying the specific service location address). Refer to Provider Memo QI-2338/ FFS 23-22. The first lines of these claims should be D9999 or D0140, according to PPS claim submission rules.

Claims for patients that were located at “public health settings” not federally registered as a FQHC or RHC service site are not eligible for PPS reimbursement.

All claims must indicate the treatment location in the “Remarks” section of the claim form. This is the location of the patient, including the name and address of “public health setting.” For example: Roosevelt High School, 1120 Nehoa Street, Honolulu, 96822. Claims that do not include the specific location of the patient will be denied.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 37-38 (Apr. 2024) (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

Originating/Spoke Site – The location where the patient is located, whether accompanied or not by a health care provider, at the time services are provided by a health care provider through telehealth, including but not limited to a health care provider’s office, hospital, critical access hospital, rural health clinic, federally qualified health center, a patient’s home, and other nonmedical environments such as schoolbased health centers, university-based health centers, or the work location of the patient. The originating site includes a patient’s residence. The U.S. Department of Health and Human Services Office for Civil Rights expects that patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances.

Non-FQHC Providers

FQHC Providers

With exceptions, the FQHC provider must be located at their contracted FQHC’s HRSA approved site or satellite.

Exceptions:

Until December 31, 2024, FQHC behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories.
If prescribing controlled substances, the provider must be located in the State of Hawai’i.

SOURCE: HI Dept of Human Services, Med-QUEST, Memo No. QI-2338/FFS 23-22, CCS-2311. (Accessed Jun. 2024).

Telehealth services may only be provided to patients if they are presented from an originating site located in either:

A federally designated Rural Health Professional Shortage Area;
A county outside of a Metropolitan Statistical Area;
An entity that participates in a federal telemedicine demonstration project.

SOURCE: Code of HI Rules 17-1737.-51.1. (Accessed Jun. 2024). – Law passed (HI Statute Section 346-59.1(c) & state plan amendment accepted prohibiting this limitation, however the prohibiting language is still present in regulation.)

Approved state plan amendment authorizes HI Medicaid to remove geographic and originating site requirements.

SOURCE: HI State Plan Amendment 16-0004. (Accessed Jun. 2024).

Teledentistry

The Medicaid rules for claims for teledentistry-related services will be consistent with the State’s rules on where teledentistry may be used.

The FFS reimbursement fee is based on the location of the eligible Medicaid provider at the time of service, Oahu or Neighboring Island.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 37 (Apr. 2024) (Accessed Jun. 2024).

FACILITY/TRANSMISSION FEE

No reference found.

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Idaho

Last updated 06/17/2024

POLICY

Services delivered through virtual care will be considered for …

POLICY

Services delivered through virtual care will be considered for reimbursement when rendered within the provider’s scope of practice and billed according to all applicable administrative rules, policy, federal and state regulations. Any covered service may be delivered via virtual care when:

The service can be safely and effectively delivered via virtual care and the medium utilized;
The service fully meets the code definition when provided via virtual care;
The service is billed with the FQ or GT modifier; and
All other existing coverage criteria are met.

Video must be provided in real-time with full motion video and audio that delivers high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication. Transmission of voices must be clear and audible. Reimbursement is also not available for services that are interrupted and/or terminated early due to equipment difficulties.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan. 30, 2024), Section 9.12 & 9.12.1 p. 133-134. Idaho MedicAide (May 2023). (Accessed Jun. 2024).

Services delivered via virtual care as defined in Title 54, Chapter 57, Idaho Code, must be identified as such in accordance with billing requirements published in the Idaho Medicaid Provider Handbook. Virtual care services billed without being identified as such are not covered. Virtual care services may be reimbursed within limitations defined by the Department in the Idaho Medicaid Provider Handbook. Fee-for-service reimbursement is not available for asynchronous services except remote monitoring. (NOTE: The term “telehealth” had been changed to “virtual care” in 2023, but the Administrative Code does not reflect that change in the currently posted version.)

SOURCE: ID Administrative Code 16.03.09 Sec. 210 (09), Pg. 25 (Accessed Jun. 2024).

For Home Health, the face-to-face encounter that initiates treatment may occur virtually.

SOURCE: ID Administrative Code 16.03.09 Sec. 723 (02)(b), Pg. 101, ID Medicaid Provider Handbook: Home Health and Hospice Services, 1.2.4.1, p. 6. (Mar. 2, 2021). (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Any covered service may be delivered via virtual care when:

The service can be safely and effectively delivered via virtual care and the medium utilized;
The service fully meets the code definition when provided via virtual care;
The service is billed with the FQ or GT modifier; and
All other existing coverage criteria are met.

Reporting of test results only is not covered as a telehealth service.

Only one eligible provider may be reimbursed per service per participant per date of service. No reimbursement is available for the use of equipment at the originating or remote sites. Reimbursement is also not available for services that are interrupted and/or terminated early due to equipment difficulties. Claims for services delivered via virtual care will be reimbursed at the same rate as face-to-face services.

Idaho Medicaid uses places of service 02 (Telehealth provided other than in patient’s home) and 10 (Telehealth provided in patient’s home). Providers must use these places of service on claims for virtual care. Claims for virtual care must include one of the following modifiers:

FQ – A telehealth service was furnished using real-time audio-only communication technology.
GT – A telehealth service was furnished using real-time audio-visual communication technology.

Additionally, providers can also use the following modifier in conjunction with one of the above:

FR – A supervising practitioner was present through a real-time two-way, audio/video communication technology.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan. 30, 2024), Sections 9.12 & 9.12.3 p. 133-134, Idaho MedicAide May 2023. (Accessed Jun. 2024).

Physician/Non-Physician Practitioner Services:

Stand-alone vaccine counseling is also reimbursable when delivered as virtual care services.

Services in the National Diabetes Prevention Program are eligible for virtual care.

Physicians and non-physician practitioners are eligible to receive reimbursement for telehealth services.

Physicians and psychiatric nurse practitioners may provide psychotherapy (CPT® 90839 and 90840) to participants in crisis via virtual care. The medical record of the participant must support a crisis service was provided for the full duration billed and demonstrate that an urgent assessment of the participant’s mental state was necessary, and/or their health or safety was at risk. The participant must be in the room for the duration of the visit or a majority of the service, which is focused on the individual. 90839 is a stand-alone code not to be reported with psychotherapy or psychiatric diagnostic evaluation codes, the interactive complexity code, or any other psychiatry section code.

SOURCE: ID Medicaid Provider Handbook: Physician and Non-Physician Practitioner (May 1, 2024), p. 51, 58, 79, 86. (Accessed Jun. 2024).

Crisis Intervention

Crisis intervention is an eligible virtual care service. If crisis intervention is provided via virtual care, all requirements must be followed under the Idaho Medicaid virtual care services policy. Further information about Virtual Care Services can be found in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.

SOURCE: ID Medicaid Provider Handbook Agency Professional (Feb. 5. 2024), p. 28. (Accessed Jun. 2024).

Therapy Services (Occupational, Physical Therapists & Speech Language Pathologists)

Virtual care services covered for therapies are real-time communication through interactive technology that enables a provider and a patient at two locations separated by distance to interact simultaneously through two-way video and audio transmission. Evaluations and reevaluations may be provided by virtual care. The therapist must certify that the services can safely and effectively be done with virtual care services and the physician or non-physician practitioner order must specifically allow the services to be provided by virtual care services. Therapists must adhere to all requirements of their licensing board for virtual care services.

Specific service codes found in manual.

SOURCE: ID Medicaid Provider Handbook, Therapy Services (May 16, 2024) pg 38 , (Accessed Jun. 2024).

Psychiatric Crisis

SOURCE: ID Medicaid Provider Handbook: Physician and Non-Physician Practitioner (May 1, 2024), p. 79. (Accessed Jun. 2024).

Laboratory Services

To be reimbursable, drug tests must be ordered by a licensed or certified healthcare professional who has performed a face-to-face evaluation of the participant (this may include telehealth if the requirements of the telehealth policy are met).

SOURCE: ID Medicaid Provider Handbook: Laboratory Services (Mar. 1, 2024), p. 22. (Accessed Jun. 2024).

Eye and Vision Services

Vision therapy is not covered for group therapy, telehealth or with home computer programs.

SOURCE: ID Medicaid Provider Handbook: Eye and Vision Services (Jan. 8, 2024), p. 54. (Accessed Jun. 2024).

Early Intervention Services (IDEA)

Medicaid reimburses for early intervention services in accordance with Medicaid established rates and reimbursement methodology. The ITP must provide virtual care servcies in accodance with the Idahol Medicaid Provider Handbook.

SOURCE: SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. 9.9.7, p. 128 (Jan. 30, 2024), (Accessed Jun. 2024).

Interpretative Services

Idaho Medicaid will reimburse for interpretation, translation, Braille and sign language services provided to participants in person or through virtual care. Reimbursement is also available when interpretive services are provided to the parent or guardian of a child under 18. The service is only eligible for reimbursement if the provider has no alternative means of oral or written communication. No additional reimbursement is available for multilingual providers that share a language with the participant. Interpreters and translators must meet state and professional licensure requirements and be at least eighteen years of age. See the Virtual Care Services section for more information about reimbursement eligibility using virtual care services.

SOURCE: SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. 9.10.3, p. 129 (Jan. 30, 2024), (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

Only one eligible provider may be reimbursed for the same service per participant per date of service.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide (May 2023). (Accessed Jun. 2024).

Idaho Medicaid therapy services, see manual for specific codes.

SOURCE: ID Medicaid Provider Handbook, Therapy Services (May 16, 2024) pg 38 (Accessed Jun. 2024).

Physicians and psychiatric nurse practitioners may provide psychotherapy to participants in crisis via telehealth, using CPT 90839 and 90840.

Physicians and non-physician practitioners are eligible to receive reimbursement for telehealth services.

SOURCE: ID Medicaid Provider Handbook, Physician and Non-Physician Practitioner. Sec. 4.34.3, Pg. 79, (4.38) 86. (May 1, 2024), (Accessed Jun. 2024).

FQHCs, RHCs & IHS

Telehealth services provided as an encounter by a facility are reimbursable if the services are delivered in accordance with the Idaho Medicaid Telehealth Policy and applicable handbooks.

FQHC, RHC or IHS providers should not report the GT or FQ modifier with encounter code T1015 but should include it with each applicable supporting codes.

SOURCE: ID Medicaid Provider Handbook: IHS, FQHC, and RHC Services, (Nov. 18, 2022), p. 30. Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan. 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide (May 2023). (Accessed Jun. 2024).

ELIGIBLE SITES

FQ – A telehealth service was furnished using real-time audio-only communication technology.
GT – A telehealth service was furnished using real-time audio-visual communication technology.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. (Jan. 30, 2024), Sections 9.12.3 p. 134, Idaho MedicAide May 2023. (Accessed Jun. 2024).

Idaho Medicaid reduces physician and non-physician practitioner reimbursement when certain procedures are provided in a facility setting. For these procedure codes there is a 30 percent reduction for physicians, and a 40 percent reduction for non-physician practitioners, of the Idaho Medicaid Numerical Fee Schedule in the following places of service (POS) including POS 02 Telehealth (Not recognized by Idaho Medicaid).

SOURCE: Idaho Medicaid Provider Handbook: Physician and Non-Physician Practitioner. 9.2, p. 131. (May 1, 2024). (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Therapy Services

Therapy services covered via virtual care are listed in the table below. Reimbursement is according to the numerical fee schedule. There is no additional fee for either the originating or the distant site.

SOURCE: ID Medicaid Provider Handbook, Therapy Services (May 16, 2024) pg 38 (Accessed Jun. 2024).

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Illinois

Last updated 07/09/2024

POLICY

Recent Legislation Effective Jan. 1, 2024

The Department and …

POLICY

Recent Legislation Effective Jan. 1, 2024

The Department and any managed care plans under contract with the Department for the medical assistance program shall provide for coverage of mental health and substance use disorder treatment or services delivered as behavioral telehealth services as specified in this Section. The Department and any managed care plans under contract with the Department for the medical assistance program may also provide reimbursement to a behavioral health facility that serves as the originating site at the time a behavioral telehealth service is rendered.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).

The Department of Healthcare and Family Services shall reimburse psychiatrists, federally qualified health centers as defined in Section 1905(l)(2)(B) of the federal Social Security Act, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing, and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services to recipients via telehealth. The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth. The Department, by rule, shall establish: (i) criteria for such services to be reimbursed, including appropriate facilities and equipment to be used at both sites and requirements for a physician or other licensed health care professional to be present at the site where the patient is located; however, the Department shall not require that a physician or other licensed health care professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services; (ii) a method to reimburse providers for mental health services provided by telehealth; and (iii) a method to reimburse providers for epilepsy treatment services provided by telehealth.

SOURCE: 305 ILCS 5/5-5.25.(b) (Accessed Jul. 2024).

Health insurance providers must include coverage for licensed dietitians, nutritionists, and diabetes educators who counsel diabetes patients, via telehealth, in the patients’ homes to remove the hurdle of transportation for patients to receive treatment.

SOURCE: 215 ILCS 5/356z.22.(g) (Accessed Jul. 2024).

Covered services under the Medical Assistance Programs include telehealth services pursuant to Sectin 140.403.

SOURCE: IL Admin Code, Title 89, Chapter 1, Subch d, Part 140, Sec. 140.3(b)(22) & c(18). (Accessed Jul. 2024).

Illinois Medicaid will reimburse for live video under the following conditions:

A physician or other licensed health care professional or other licensed clinician, mental health professional or qualified mental health professional must be present with the patient at all times with the patient at the originating site;
The distant site provider must be a physician, physician assistant, podiatrist or advanced practice nurse who is licensed by Illinois or the state where the patient is located. For telepsychiatry, it must be a physician who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program;
The originating and distant site provider must not be terminated, suspended or barred from the Department’s medical programs;
Telepsychiatry: The distant site provider must personally render the telepsychiatry service;
Medical data may be exchanged through a telecommunication system. For telepsychiatry it must be an interactive telecommunication system;
The interactive telecommunication system must, at a minimum, have the capability of allowing the consulting distant site provider to examine the patient sufficiently to allow proper diagnosis of the involved body system. The system must also be capable of transmitting clearly audible heart tones and lung sounds, as well as clear video images of the patient and any diagnostic tools, such as radiographs;
Telepsychiatry: Group psychotherapy is not a covered telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403(b). (Accessed Jul. 2024).

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

For telepsychiatry services, a staff member meeting the minimum qualifications of a mental health professional (MHP) must be present at all times with the patient at the originating site.

When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 26-27, (June 2021). (Accessed Jul. 2024).

See regulations for requirements during a public health emergency.

SOURCE: IL Admin. Code, Title 89,140.403. (Accessed Jul. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Appropriate CPT codes must be billed with the GT modifier for telemedicine and telepsychiatry services and the appropriate Place of Service code, 02, telehealth. Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider. Non-enrolled providers rendering services as a distant site provider shall not be eligible for reimbursement from the Department, but may be reimbursed by the originating site provider from their facility fee payment.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 26, (June 2021), IL Dept. of Healthcare and Family Svcs, Handbook for Podiatric Services, Ch F-200 Policy and Procedures 220.6.2, p. 27. (Oct. 2016). (Accessed Jul. 2024).

See Encounter Clinic Services Appendices and Handbook Supplement (Sept. 2020) for billing examples.

SOURCE: Handbook for Encounter Clinic Services, Chapter D-200, Sept. 23, 2020 (Accessed Jul. 2024).

There is no reimbursement for group psychotherapy as a telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403. (Accessed Jul. 2024).

Modifier GT – identifies telehealth interactions using both audio and video telecommunications systems.

Modifier 93 (Effective with dates of service beginning July 1, 2022) – identifies telehealth interactions using an audio-only telecommunications system.

The system updates allow providers to bill a service with modifier “GT” or “93” and a service without modifier “GT” or “93” for the same customer, same date of service, and same procedure code and get reimbursed for both services.

SOURCE: Provider Notice Rate Adjustment and Telehealth Billing Guidance (Jan. 9, 2023). (Accessed Jul. 2024).

Interprofessional Consultation for Psychiatric Services

Certain procedure codes for interprofessional consultation is allowed for the delivery of psychiatric services. See memo for codes.

SOURCE: IL HFS Provider Notice (Feb. 3, 2023). (Accessed Jul. 2024).

Recent Legislation Effective Jan. 1, 2024

Mental Health and Substance Use Disorder

For purposes of reimbursement, the Department and any managed care plans under contract with the Department for the medical assistance program shall reimburse a behavioral health care professional or behavioral health facility for behavioral telehealth services on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by a behavioral health care professional or behavioral health facility. This subsection applies only to those services provided by behavioral telehealth that may otherwise be billed as an in-person service.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).

Fee Schedules Indicate telehealth eligible services with appropriate modifiers or service code.

SOURCE: Adaptive Behavior Support Services (Jan. 26, 2022), Dental (Jan. 1, 2023), (Accessed Jul. 2024).

Podiatry

Codes and billing examples for podiatry services.

SOURCE: Handbook for Podiatric Services (Appendices), Appendix F-6 (p. 35). (Accessed Jul. 2024).

Home Health Services

A face-to-face encounter may occur through telehealth.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Home Health Services. Ch. R-200 Policy and Procedures, R-205.1 p. 19, (May 2016). IL Dept. of Healthcare and Family Svcs., Handbook for Care Coordination and Support Organization Provider (Oct. 5, 2022), p. 31. IL Admin Code, Title 89, Chapter 1, Subch d, Part 140, 140.471(d)(2)(C). (Accessed Jul. 2024).

POS 10 is a new place of service code that specifies a distant site telehealth service rendered to a patient who is located in their home. It does not replace POS 02. The description for POS 02 has been changed to, “Telehealth Provided Other than in Patient’s Home” and it is still a valid distant site telehealth service POS code. POS 10, when applicable, should be submitted for claims with dates of service beginning April 1, 2022.

SOURCE: Provider Notice Issued 3/21/22: Modifier 93 and Place of Service Code 10 Implementation. (Accessed Jul. 2024).

Community Based Behavioral Services

Effective with dates of service beginning October 1, 2021, providers delivering services via audio or video communication must utilize the appropriate telehealth POS code, consistent with Section 207.3.7, when billing for services. Providers submitting claims for ‘on-site’ services that include services rendered both by telehealth and face-to-face must exclude the telehealth services from the “roll up” combination of on-site units. Rather, services delivered via telehealth must be billed with the appropriate telehealth modifier (GT or 93) and POS (02 or 10) on a service line separate from other ‘rolled up’ on-site services rendered face-to-face to the same recipient for the same procedure code and modifier combination.

Providers billing a service that was performed via audio or video communication must append the procedure code with appropriate modifier and POS to indicate telehealth as the mode of service delivery. This coding is needed for HFS to track the mode of service delivery. The modifier and place of service codes are for reporting purposes only and do not affect current payment methodology. Additional telehealth modifiers and POS have been adopted effective with dates of service beginning July 1, 2022. The table below provides guidance to providers utilizing telehealth on the appropriate telehealth modifiers and POS based upon the date of service. (See manual for additional information).

The new billing instructions apply to any service being billed as a telehealth service, whether it is:

A code identified in the Community Based Behavioral Services Handbook that historically could be provided via phone and/or video delivery modes independent of the current public health emergency, or
A behavioral health service allowed via telehealth per the current public health emergency telehealth policy stated in the March 20, 2020 provider notice. This list of codes includes the following services from the CBS Fee Schedule: 96110, 96112, 96127 and H1000.

SOURCE: Medicaid Provider Notice “Use of Modifier GT and Place of Service Code 02 to Specify Telehealth Delivery Mode for Behavioral Health Services” & IL Dept. of Healthcare and Family Svcs., Handbook for Community-Based Behavioral Services Providers, 208.3.1 pg. 23-26 (June 6, 2022). (Accessed Jul. 2024).

The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth.

SOURCE: ILCS 5/5.25, (Accessed Jul. 2024).

Department provides coverage for epilepsy treatment services via telehealth as required under Public Act 102-0207. Coverage is provided under both Medicaid fee-for-service and the managed care plans.

SOURCE: Medicaid Provider Notice “Confirmation of Reimbursement for Epilepsy Specialists via Telehealth (9/24/21)” (Accessed Jul. 2024).

Telehealth services for persons with intellectual and developmental disabilities. The Department shall file an amendment to the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities authorized under Section 1915(c) of the Social Security Act to incorporate telehealth services administered by a provider of telehealth services that demonstrates knowledge and experience in providing medical and emergency services for persons with intellectual and developmental disabilities. The Department shall pay administrative fees associated with implementing telehealth services for all persons with intellectual and developmental disabilities who are receiving services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities.

For dates of service on and after January 1, 2025, the Department shall pay negotiated, agreed upon administrative fees associated with implementing telehealth services for persons with intellectual and developmental disabilities who are receiving Community Integrated Living Arrangement residential services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities. The implementation of telehealth services shall not impede the choice of any individual receiving waiver-funded services through the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities to receive in-person health care services at any time. The Department shall ensure individuals enrolled in the waiver, or their guardians, request to opt-in to these services. For individuals who opt in, this service shall be included in the individual’s person-centered plan. The use of telehealth services shall not be used for the convenience of staff at any time nor shall it replace primary care physician services.

SOURCE: 305 ILCS 5/5-5a.1 as amended by SB 3268. (Accessed Jul. 2024).

Diabetes Prevention Program (DPP) & Diabetes Self-Management Education and Support (DSMES)

DPP services are provided in-person or via telehealth/virtually during sessions that occur at regular, periodic intervals over the course of one year.

DSMES services may be provided in the home, clinic, hospital outpatient facility, via telehealth, or any other setting as authorized and include: counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control; counseling and skill building to facilitate the knowledge, skill and ability necessary for diabetes self-care; and nutritional counseling services.

SOURCE: Medicaid Provider Notice “Billing Update for Diabetes Prevention and Management Programs (7/29/22)” (Accessed Jul. 2024).

Care Coordination and Support Organization (CCSO)

Care Coordination and Support (CCS) services are reimbursed if certain requirements met, including completing two oral communications with family within the calendar month via telephonic, video or in-person.

SOURCE: IL Dept. of Healthcare and Family Services, Care Coordination and Support Organization Provider Handbook (Oct. 5, 2022), p. 56-57. (Accessed Jul. 2024).

Medical Equipment

Effective July 1, 2017, to be eligible for reimbursement by the Department, certain medical equipment and supplies will be subject to a face-to-face encounter. The Department will, at a minimum, require a face-to-face encounter for equipment and supplies for which Medicare requires a face-to-face encounter. The face-to-face patient encounter may occur through telehealth, in compliance with Section 140.403.

SOURCE: IL Admin Code, Title 89, Chapter 1, Subchapter d, Part 140, Sec. 140.475(g)(3). (Accessed Jul. 2024).

ELIGIBLE PROVIDERS

The Department of Healthcare and Family Services required to reimburse psychiatrists, federally qualified health centers, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services via telehealth. The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth.

SOURCE: 305 ILCS 5/5.25, (Accessed Jul. 2024).

For telemedicine services, the distant site provider must be a physician, physician assistant, podiatrist, or advanced practice nurse who is licensed by the State of Illinois or by the state where the patient is located.

Practitioner Handbook: When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit. Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider. Non-enrolled providers rendering services as a distant site provider shall not be eligible for reimbursement from the Department, but may be reimbursed by the originating site provider from their facility fee payment.
Podiatry Handbook: Services rendered by an APN can be billed under the collaborating physician’s NPI, or if the APN is enrolled, under the APN’s NPI. When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

For telepsychiatry, the distant site provider must be a physician who is licensed by the State of Illinois or by the state where the patient is located who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program.

Practitioner Handbook: To be eligible for reimbursement for telepsychiatry services, physicians must enroll in the correct specialty/sub-specialty in IMPACT.
Encounter Clinic Handbook: Telepsychiatry is not a covered service when rendered by an APN or PA. Group psychotherapy is not a covered telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403(b); IL Dept. of Healthcare and Family Svcs., Handbook for Podiatrists (physician services only), F-200, F-220.6.2 p. 28 (Oct. 2016); IL Dept Of Healthcare and Family Svcs, Handbook for Providers of Podiatric Services (Oct 2016), p. 27, & Handbook for Practitioner Services. Ch. 200, 220.5.7 p. 26 (June 2021) & Handbook for Encounter Clinic Services. Ch. 200, 210.2.2 pg. 17. (Aug. 2016). (Accessed Jul. 2024).

An encounter clinic serving as the distant site shall be reimbursed as follows:

If the originating site is another encounter clinic, the distant site encounter clinic shall receive no reimbursement from the Department. The originating site encounter clinic is responsible for reimbursement to the distant site encounter clinic; and
If the originating site is not an encounter clinic, the distant site encounter clinic shall be reimbursed for its medical encounter. The originating site provider will receive a facility fee.

See Encounter Clinic Services Appendices supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Admin. Code Title 89, 140.403; IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010; Handbook for Encounter Clinic Services. Ch. 200, pg. 17. Aug. 2016 & IL All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Jul. 2024).

Effective with dates of service beginning October 1, 2021, providers billing a service from the Community Based Behavioral Services Fee Schedule that was performed via audio or video communication must append the procedure code with modifier GT and use Place of Service Code 02. This coding is needed for HFS to track the mode of service delivery. The GT modifier and Place of Service Code 02 are for reporting purposes only and do not affect current payment methodology.

The new billing instructions apply to any service being billed as a telehealth service, whether it is:

A code identified in the Community Based Behavioral Services Handbook that historically could be provided via phone and/or video delivery modes independent of the current public health emergency, or
A behavioral health service allowed via telehealth per the current public health emergency telehealth policy stated in the March 20, 2020 provider notice. This list of codes includes the following services from the CBS Fee Schedule: 96110, 96112, 96127 and H1000.

The following providers billing from the Community Based Behavioral Services Fee Schedule are impacted:

Community Mental Health Centers
Behavioral Health Clinics
Physicians
Licensed Clinical Psychologists
Licensed Clinical Social Workers

SOURCE: Medicaid Provider Notice “Use of Modifier GT and Place of Service Code 02 to Specify Telehealth Delivery Mode for Behavioral Health Services” (Accessed Jul. 2024)

Local education agencies may submit telehealth services as a certified expenditure.

SOURCE: IL Admin. Code Title 89, 140.403(c)(1)(B). (Accessed Jul. 2024).

ELIGIBLE SITES

The Department shall reimburse any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including substance abuse centers licensed by the Department of Human Services’ Division of Alcoholism and Substance Abuse.

SOURCE: ILCS 5/5.25(c), (Accessed Jul. 2024).

SOURCE: Provider Notice Issued 3/21/22: Modifier 93 and Place of Service Code 10 Implementation. (Accessed Jul. 2024).

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

For telepsychiatry services, A physician, licensed health care professional or other licensed clinician, mental health professional (MHP), or qualified mental health professional (QMHP), must be present at all times with the patient at the originating site.

SOURCE: IL Admin. Code Title 89, 140.403(b) & IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 25, (June 2021). (Accessed Jul. 2024).

IL Healthcare and Family Services recognizes the following as valid originating sites: physician’s office, podiatrist’s office, local health department, Community Mental Health Center, Encounter Rate Clinics, and outpatient hospital.

For telepsychiatry services, a staff member meeting the minimum qualifications of a mental health professional (MHP) must be present at all times with the patient at the originating site.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 25, (June 2021). (Accessed Jul. 2024).

See handbook supplement for telehealth billing examples.

SOURCE: All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Jul. 2024).

An encounter clinic is eligible as an originating site and is responsible for ensuring and documenting that the distant site provider meets the department’s requirements for telehealth and telepsychiatry services since the clinic is responsible for reimbursement to the distant site provider.

See Encounter Clinic Services Appendices supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010; IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. (June 2021) Ch. 200, p. 25; Handbook for Podiatrists, F-200, p. 27 (Oct. 2016); & Handbook for Encounter Clinic Services. Ch. D-200, pg. 17. Aug. 2016. (Accessed Jul. 2024).

Recent Legislation Effective Jan. 1, 2024

Mental Health and Substance Use Disorder

There shall be no restrictions on originating site requirements for behavioral telehealth coverage or reimbursement to the distant site under this Section other than requiring the behavioral telehealth services to be medically necessary and clinically appropriate.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating site providers may submit claims for a facility fee for each telehealth service encounter using HCPCS Code Q3014/Telehealth Originating Site Facility Fee.

Eligible facilities include:

Physician’s office;
Podiatrist’s office
Local health departments
Community mental health centers
Outpatient hospitals

SOURCE: IL Handbook for Practitioners Rendering Medical Services, Ch. 200, p. 26 (June 2021) & Handbook for Podiatrists, F-200, p. 27 (Oct. 2016). (Accessed Jul. 2024).

Hospitals Billing with Revenue Code 0780 and HCPCS Code Q3014

HCPCS code Q3014 must be identified on the same revenue line with Revenue Code 0780. If any other procedure code is billed with Revenue Code 0780, the claim will be rejected with error code T55 – Missing/Invalid HCPCS for Revenue Code 0780.

Other services may be billed as necessary on the same outpatient claim with a telehealth facility fee, but the telehealth service must be identified as described in this provider notice. No modifier is required for the telehealth service.

SOURCE: Medicaid Provider Notice “Hospitals Billing as the Telehealth Originating Site” (Mar. 2, 2021). (Accessed Jul. 2024)

Sites approved as valid originating facility sites were expanded. The March 20, 2020 notice contained a list of sites that included “providers who receive reimbursement for a patient’s room and board, including nursing facilities and Intermediate Care Facilities for the Developmentally Disabled.” For further clarification, this category would also include Family Support Program residential providers, Medically Complex Facilities for Persons with Developmental Disabilities, and Specialized Mental Health Rehabilitation Facilities.

Facility Fee Billing Instructions for Hospice Agencies:

In situations where a hospice patient in a long term care facility is in need of a telehealth service, the hospice may submit charges for the facility fee as an originating telehealth site.

Use Revenue Code 0657 in conjunction with HCPCS code Q3014 and identify the number of Service Units (telehealth occurrences) provided in the billing period.

The telehealth facility fee service cannot be billed separately and must be included on a claim containing the hospice’s usual charges.

Facility Fee Billing Instructions for Hospitals:

Hospitals are already able to bill as a non-institutional provider originating site, as stated in the Handbook for Practitioner Services, topic 202.1.4 – Allowable Fee-for-Service Charges by Hospitals.

All Other Originating Facility Sites – The Department is currently working to implement a facility fee payment system for these sites and additional information will be forthcoming.

SOURCE: Provider Notice Telehealth Expansion Billing Instructions (March 30, 2020). (Accessed Jul. 2024).

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Indiana

Last updated 08/06/2024

POLICY

The Indiana Health Coverage Programs (IHCP) covers select medical, …

POLICY

The Indiana Health Coverage Programs (IHCP) covers select medical, dental and remote patient monitoring services delivered via telehealth. IHCP coverage is also available for the virtual delivery of certain nonhealthcare services (such as case management) for members who are eligible to receive such services. For applicable procedure codes, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. Most telehealth services must be provided via video and audio, although a few designated telehealth services can be provided via audio only. Audio-only delivery is allowable for all nonhealthcare virtual services.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 1. (Accessed Aug. 2024).

Indiana Code requires reimbursement for medically necessary telehealth services for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Community Mental Health Centers, Critical Access Hospitals, a home health agency under IC 16-27-1, and a provider determined by the office to be eligible, providing a covered telehealth service.

SOURCE: IN Code, 12-15-5-11 (Accessed Aug. 2024).

All services delivered through telehealth are subject to the same limitations and restrictions as they would be if delivered in-person

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, June 8, 2021, (Accessed Aug. 2024).

In any telemedicine encounter, there will be the following:

A distant site;
An originating site;
An attendant to connect the patient to the provider at the distant site; and
A computer or television monitor at the distant and originating sites to allow the patient to have real-time, interactive; and face-to-face communication with the distant provider via IATV technology.

SOURCE: IN Admin. Code, “Article 5,” Title 405, 5-38-3 & 4., p. 199 (Accessed Mar. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Providers are allowed to use telehealth for the medical, dental and remote patient monitoring services listed in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. The following services may not be provided using telehealth:

Surgical procedures
Radiological services
Laboratory services
Anesthesia services
Durable medical equipment (DME)/home medical equipment (HME) services
Transportation services

Office visits conducted via telehealth are subject to existing service limitations for office visits. Telehealth office visits billed using applicable codes from Telehealth and Virtual Services Codes (accessible from the Code Sets page at in.gov/medicaid/providers) are counted toward the member’s office visit limit. See the Evaluation and Management Services module for information about office visit limitations.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 2-3. Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, p. 2 June 8, 2021, (Accessed Aug. 2024).

Group psychotherapy services and 2024 Annual HCPCS Codes Update – new codes added.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202425 (Feb. 29, 2024). (Accessed Aug. 2024).

IHCP reimbursement for telehealth services is limited to the medical, dental and remote patient monitoring procedure codes listed in the telehealth code set (see the Telehealth Services Allowed and Excluded section). Additionally, the rendering NPI on the claim must be enrolled in the IHCP under one of the specialties allowable for telehealth services (see the Practitioners Eligible to Provide Telehealth Services section). All services delivered via telehealth must be billed with one of the following place of service (POS) codes:

02 – Telehealth provided other than in patient’s home
10 – Telehealth provided in the patient’s home

The procedure code billed must appear on the telehealth code set (Tables 1–3 of Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers). IIn addition, an appropriate telehealth modifier may be required, depending on the type of service:

Medical services – All medical services delivered via telehealth (with the exception of services delivered through a Home- and Community-Based Services [HCBS] or Money Follows the Person [MFP] program) require one of the following modifiers:

95 – Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
93 – Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 3-4 Indiana Health Coverage Programs ICHP Bulletin BT202249 (June 30, 2022). (Accessed Aug. 2024).

In December 2022, IHCP expanded and clarified telehealth coverage and note it will be effective December 9, 2022. The updated coverage applies to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid. The telehealth and virtual services code set is used by both fee-for-service (FFS) and managed care delivery systems. This updated code set will remain in place for the remainder of 2022 and 2023, and will be reevaluated by the Office of Medicaid Policy and Planning (OMPP) at the end of 2023.

Updated Code Set as of May 16, 2024, (Accessed Aug. 2024).

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202425 (Feb. 29, 2024). IN Health Coverage Programs (IHCP) Bulletin BT 202297 (Nov 8, 2022). Past bulletins: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, p. 2 June 8, 2021, ICHP BT2020106 Indiana Health Coverage Programs ICHP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

As published in IHCP Bulletin BT202239, for a practitioner to receive reimbursement for telehealth services, the procedure code must be listed in the telehealth and virtual services code set, and must be a service for which the member is eligible. Additionally, the claim detail must have:

One of the following place of service (POS) codes:

02 – Telehealth provided other than in patient’s home
10 – Telehealth provided in the patient’s home

One of the following modifiers:

95 – Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
93 – Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system

Modifier 93 (audio-only) is allowable only for certain, designated telehealth services. Effective Dec. 9, 2022, the IHCP will allow reimbursement for the telehealth services specified in Table 1 when billed with the appropriate POS code and the audio-only modifier (93).

SOURCE: Indiana Health Coverage Programs ICHP Bulletin BT202297 (Nov 8, 2022), p. 1. (Accessed Aug. 2024).

A valid FQHC or RHC encounter is defined as a face-to-face visit (either in person or via telehealth) between an IHCP member and a qualifying practitioner (see the Rendering Providers section) at an FQHC, RHC or other qualifying, non-hospital setting. When billing valid encounters provided by telehealth, When billing valid telehealth encounters, the encounter code (T1015 or D9999) should be billed as usual, and each service provided during the encounter must include an appropriate telehealth POS code (02 or 10) and telehealth modifier (93 or 95), as described in the FQHC and RHC Telehealth Services section of the Telehealth and Virtual Services module.

SOURCE: Medicaid Federally Qualified Health Centers and Rural Health Clinics Module, (Jan 2022 edition, published May 7, 2024), p. 10, 12, (Accessed Aug. 2024).

When the FQHC or RHC is the distant site, the service provided by the FQHC or RHC must meet the requirements both for a valid encounter and for an approved telehealth service. The claim must include the following:

Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 10, 11, 12, 31, 32, 50 or 72
One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 6 (Accessed Aug. 2024).

For purposes of a community mental health center, telehealth services satisfy any face to face meeting requirement between a clinician and consumer.

SOURCE: IN Code, 12-15-5-11(f) IHCP Division of Mental Health and Addiction, Adult Mental Health Habilitation Services (July 25, 2024), p. 20; IHCP Division of Mental Health and Addiction, Behavioral and Primary Healthcare Coordination Service (July 1, 2023), p. 26. (Accessed Mar. 2024).

Adult Mental Health Habilitation Services

Adult Mental Health Habilitation (AMHH) Home- and Community-Based Habilitation and Support services are individualized services provided face to face or via telehealth according to Indiana Administrative Code (IAC) that are focused on the member’s health, safety and welfare. Valid telehealth services can be found on Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers

Program standards for Adult Mental Health Habilitation (AMHH) Therapy and Behavioral Support Services and Addiction Counseling include the following:

Services may be provided face to face or with telehealth according to the IAC with the member or with family members or nonprofessional caregivers with or without the member present.

For Medication Training and Support, program standard for these services include that services provided that are not face-to-face or telehealth, according to the IAC, with the member must meet the following standards:

The member must be the focus of the service.
Documentation must support how the service benefits the member.

SOURCE: IHCP Division of Mental Health and Addiction, Adult Mental Health Habilitation Services (July 25, 2024), p. 61, 63, 69, 73, 86 (Accessed Aug. 2024).

Behavioral and Primary Healthcare Coordination (BPHC) Services

Telehealth may be used for clinical evaluations in the BPHC application process, for developing the Individualized Integrated Care Plan (IICP), and ongoing review of the IICP.

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Behavioral and Primary Healthcare Coordination Services (October 26, 2023), p. 33, 41, 46. 71 (Accessed Aug. 2024).

The Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) and Division of Mental Health and Addiction (DMHA) received approval from the Centers for Medicare & Medicaid Services (CMS) to renew the Behavioral and Primary Healthcare Coordination (BPHC) service program. The renewal will go into effect on June 1, 2024. The renewal of BPHC programming and services allows for an additional five years of the BPHC service. The BPHC service program offers one service, which consists of coordinated healthcare activities to manage the behavioral health/addiction and physical healthcare needs of eligible members. The service includes logistical support, advocacy and education to assist individuals in navigating the healthcare system, and activities that help members gain access to needed physical and behavioral health services to manage their health conditions. The following updates are included in the BPHC program:

Quality improvement (QI) activities will verify services provided fulfill the person-centered plan (PCP) established with the individual receiving services.
Medicaid allowances for telehealth services.

SOURCE: Indiana Health Coverage Programs, IHCP Bulletin, BT202440 (April 4, 2024). (Accessed Aug. 2024).

Nonhealthcare Virtual Services

Nonhealthcare virtual services are services centering on patient wellness and case management that are delivered between a patient and a provider via interactive electronic communications technology. A licensed practitioner listed under IC 25-1-9.5-3.5 is not required to perform these services, as they are not considered healthcare services under the definition listed in IC 25-1-9.5-2.5. For a list of nonhealthcare procedure codes allowable for virtual delivery, see the Procedure Codes for Nonhealthcare Virtual Services table in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

Nonhealthcare virtual services must be billed with POS code 02 or 10. These services and do not require modifiers 93 or 95. All services in this category can be provided either through audio and video technology or via audio only.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 5 (Accessed Aug. 2024).

Nonhealthcare virtual services take place between a patient and a provider via interactive electronic communications technology. These services do not require a licensed practitioner listed in IC 25-1-9.5-3.5 to perform the service virtually, as the services are not considered healthcare services under the definition listed in IC 25-1-9.5-2.5 and, therefore, do not fall under the definition of telehealth by the IHCP. As specified in Table 2, nonhealthcare virtual services must be billed with a POS of 02 or 10, and do not require modifiers 93 or 95. All services in this category can be provided via audio only.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

Telehealth Dental Services

The use of modifiers 95 or 93 is not required for dental services delivered via telehealth. Dental services cannot be delivered via audio-only telehealth.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 4, Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

Intensive Outpatient Treatment via Telehealth

The IHCP reimburses for intensive outpatient treatment (IOT) services (procedure codes H0015 and S9480) when delivered via telehealth. The IHCP is approaching this temporary policy expansion as a pilot initiative, where any healthcare provider engaging in telehealth IOT will be opting in to the analysis of the efficacy of this model through data collection and analysis. This data collection and analysis will be administered through the state and is intended to have a minimal administrative impact on providers. All providers submitting claims for telehealth IOT will automatically be included in the study and are expected to participate by providing data if requested. Telehealth IOT will be available for 12 months after which the data collected will be analyzed by the Division of Mental Health and Addiction (DMHA). IOT requires prior authorization for medical necessity, regardless of whether it is delivered in person or via telehealth. See manual for other criteria.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 7 (Accessed Aug. 2024).

After receiving feedback from providers over an allotted 30-day period, the IHCP has determined that IOT services (procedure codes H0015 and S9480) will be reimbursable when delivered via telehealth. This service will be added to the 2022 telehealth and virtual services code set. See bulletin for more instructions.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

With the exception of services billed by a federally qualified health center (FQHC) or rural health clinic (RHC) (see the Telehealth Services for FQHCs and RHCs section) or RPM services billed by a home health agency (see the RPM Billing and Reimbursement for Home Health Agencies section), the payment for telehealth services is equal to the current Fee Schedule amount for the procedure codes billed (see the IHCP Fee Schedules page at in.gov/medicaid/providers).

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 3, (Accessed Aug. 2024).

Skills Training and Development Rendered Via Telehealth

As published in BT202249, the IHCP reimburses for H2014 – Skills training and development, per 15 minutes when the service is rendered through an audiovisual telehealth modality. Skills training and development is covered only for members who have access to Medicaid Rehabilitation Option (MRO) services. The OMPP, in partnership with the Division of Mental Health and Addiction (DMHA), developed the following service parameters for when telehealth delivery satisfies the “face-to-face” contact required for this service. Providers are expected to have these service parameters in place by Dec. 9, 2022, when rendering skills training and development via telehealth. See bulletin for additional information.

SOURCE: IHCP Expands and Clarifies Telehealth Coverage BT 202297 (Nov. 8, 2022), p. 2-3. (Accessed Aug. 2024).

Home and Community-Based Services

Caregiver Coaching provided in the home of the participant, virtually or telephonically and through Health Insurance Portability and Accountability Act (HIPAA) secure communication platforms that allow for real time and asynchronous communication between caregivers and caregiver coaches and collaboration with waiver care managers/service coordinators.

Caregiver Coaching services may be delivered telephonically and through HIPPA secure electronic communication platforms that enable a caregiver coach and a caregiver to communicate efficiently and in a manner convenient to the caregiver.

SOURCE: IHCP Office of Medicaid Policy and Planning, Home and Community Based Services: Indiana PathWays for Aging Waiver, p. 50-51. (Accessed Aug. 2024).

Mobile Crisis Intervention Services

Follow-up stabilization services: Follow up contacts in-person, via phone, or telehealth up to 14 days following initial crisis intervention and can be billable up to 90 days.

SOURCE: IHCP Adding Coverage for Mobile Crisis Intervention Services BT 202364 (Jun. 15, 2023) & IHCP Bulletin ICHP Covers Mobile Intervention Services Retroactive to July 1, 2023 (Dec. 12, 2023). (Accessed Aug. 2024).

Home Health Services

The IHCP covers telehealth services provided by home health agencies.

SOURCE: IHCP Home Health Services Module (Oct. 3, 2023), p. 8. (Accessed Aug. 2024).

Opioid Treatment Program

POS codes 02 – Telehealth provided other than in patient’s home and 10 – Telehealth provided in patient’s home can be used when billing OTP services. It should be noted that by end of 2023, the Office of Medicaid Policy and Planning will be reevaluating the telehealth service codes. If any changes to these POS codes occur, it will be noted in a future bulletin.

SOURCE: IHCP Bulleting BT 2023151 (Nov. 2, 2023), p. 2. (Accessed Aug. 2024).

Behavioral and Primary Healthcare Coordination Service

Evaluations and meetings with patient maybe conducted face-to-face or with telehealth.

SOURCE: Division of Mental Health and Addiction Behavioral and Primary Healthcare Coordination Service (Oct. 26, 2023), p. 33, 46. (Accessed Aug. 2024).

Adult Mental Health Habilitation Services

Evaluations and reassessments may be conducted face-to-face or via telehealth. Certain information must be included and in some cases specific requirements must be met. See manual for more information.

All clients being considered for telehealth services must be given the option of in-person services prior to telehealth being selected as modality.

The number of in-person visits and the percentage of time telehealth will be the delivery method of service will be based on what is clinically appropriate and in agreement with the consumer and/or legal guardian.

The use of telehealth should protect against isolating participants by offering services that are in person and shall be invoked to prioritize and facilitate community integration.

Telehealth services shall consider and respond to all accessibility needs, including whether hands-on or physical assistance is needed to render the service.

Telehealth services must ensure the health and safety of the individual receiving services by adhering to all abuse, neglect and exploitation prevention practices that apply to in-person treatment, as well as by providing participants with resources on how to report incidences of abuse, neglect and exploitation.

Habilitation and support is not permissible via audio-only telehealth modalities. The IHCP reimburses for H2014 – Skills training and development, per 15 minutes (see Table 2) when the service is rendered through an audiovisual telehealth modality.

These services (specific HPCCS Codes listed on pages 70, 75, 87) cannot be delivered via audio-only telehealth per IHCP policy, but can be delivered via audiovisual telehealth. If a member has eligibility to receive these services in person through the IHCP, then they are eligible to receive these services via telehealth. For more information, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

Adult Mental Health Habilitation (AMHH) Addiction Counseling services consist of a series of planned and organized face-to-face or telehealth, according to Indiana Administrative Code. Addiction professionals and other clinicians provide counseling interventions that work toward the member’s recovery goals identified in the Individualized Integrated Care Plan (IICP) as they pertain to substance use-related disorders. Valid telehealth services can be found on Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers

T1016 – Care Coordination – If a member has eligibility to receive these services in person through the IHCP, then they are eligible to receive these services via telehealth. For more information, see Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. (See manual for more detail).

Adult Mental Health Habilitation (AMHH) Medication Training and Support services involve face-to-face or telehealth according to Indiana Administrative Code, services provided to the member, in an individual or group setting, for the purpose of:

Monitoring medication compliance
Providing education and training about medications
Monitoring medication side effects
Providing other nursing or medical assessment

SOURCE: Division of Mental Health and Addiction, Adult Mental Health Habilitation Services Module (July 25, 2024), p. 20, 41, 56, 63-64, 69, 70, 73, 75, 81, 83, 85, 86, 87. (Accessed Aug. 2024).

Outpatient Institutional Claims for Telehealth Services

For providers that use the outpatient institutional claim (UB-04 claim form, IHCP Provider Healthcare Portal institutional claim or 837I electronic transaction), services delivered via telehealth should be billed as follows:

If the service can be billed with a procedure code, providers should enter the procedure code and, if applicable, use the appropriate modifier (93 or 95) to indicate that the service was delivered via telehealth. POS codes are not used on outpatient claims.
If the service cannot be billed with a procedure code (for example, procedure codes cannot be used with revenue codes 905 or 906), the service should be billed as it normally would if delivered in person. Procedure code, modifier and POS code requirements do not apply in this case. Providers are advised to mark in their patient records that the service was delivered via telehealth.

In either case, the service provided must be a one that is allowable for telehealth delivery, as indicated on the telehealth code set (Tables 1–3 of Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers).

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb, 29. 2024), p. 4-5, (Accessed Aug. 2024).

Applied Behavioral Analysis Therapy Services via Telehealth

The IHCP provides coverage for applied behavior analysis (ABA) therapy when medically necessary for the treatment of autism spectrum disorder (ASD). All ABA therapy services require prior authorization. Besides the PA criteria outlined in the Behavioral Health Services module, procedure codes 97155 and 97156 are subject to the following additional requirements when rendered via telehealth:

Credentialed registered behavior technicians (RBTs) may not deliver any ABA service via telehealth. Only a health service provider in psychology (HSPP) or a licensed or board-certified behavior analyst (BCBA) are eligible for using telehealth when supervising the delivery of ABA services remotely.
Procedure code 97155 is reimbursable via telehealth only when an HSPP or BCBA is providing guidance/supervision to an RBT remotely, and the RBT is rendering adaptive behavioral treatment in person to the member.
All ABA services must include synchronous audiovisual interaction. No ABA services are reimbursable when delivered via audio-only telehealth.

The complete list of procedure codes for applied behavior analysis therapy can be found in Behavioral Health Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. Procedure codes 97155 and 97156 are the only two ABA services that are allowable as telehealth.

For dates of service on and after Jan. 1, 2024, all ABA services must be billed with an appropriate modifier to indicate the credentials of the practitioner delivering the service. When ABA services are delivered via telehealth, modifier 95 must also be included.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb 29, 2024), p. 8, (Accessed Aug. 2024).

Addiction Counseling, Behavioral Health Counseling & Therapy, Medication Training and Support

Addiction Counseling, Behavioral Health Counseling, Medication Training and Support, and Skills and Training Development may be delivered via an audiovisual telehealth modality. This service is not permissible via audio-only telehealth modalities. If behavioral health assistance needs to be rendered via audio-only telehealth modalities, the following procedure codes are reimbursable via audio-only telehealth:

H0038 – Self-help/peer service, per 15 minutes

H2011 – Crisis intervention service, per 15 minutes

See the Behavioral Health Services module for more information on the peer recovery and crisis intervention services. See the Telehealth and Virtual Services module for more information about rendering and billing for telehealth services.

Skills Training and Development may be delivered via an audiovisual telehealth modality when the following service parameters are met:

All members being considered for telehealth services must be given the option of in-person services prior to telehealth being selected as the modality.
The member must indicate that telehealth is their preferred method for receiving services.
The member must have documented acknowledgement of receipt of informed consent about risks and benefits of the telehealth modality.
Within 30 days of the first telehealth session occurring, a licensed behavioral health practitioner, HSPP or overseeing psychiatric medical professional must document verification that telehealth is thought to be an effective modality for the member based on symptoms, severity and access to services.
Use of the telehealth modality must be formally reviewed with the member every 90 days and adjusted based on need or efficacy.
If the member is not progressing or stabilizing, evaluation of how treatment will be adjusted must be documented. This adjustment may include increasing in-person sessions.
All Skills Training and Development sessions should have clearly documented connection to diagnosis and/or treatment goals.
At minimum, the member must have an in-person session with a member of the treatment team every 90 days. This session may be in the home, community or office setting.

SOURCE: IHCP Medicaid Rehabilitation Option Services, p. 10, 14, 22, 29. (Feb. 27, 2024). (Accessed Aug. 2024).

ELIGIBLE PROVIDERS

In response to Indiana House Enrolled Act 1352 (2023), the Indiana Health Coverage Programs (IHCP) has implemented a new telehealth-only provider enrollment for providers that wish to perform only telehealth services (with no physical site where patients are seen) and that meet the Indiana licensure and other special requirements outlined in this bulletin. This telehealth-only provider enrollment option is currently available on the IHCP Provider Healthcare Portal. See bulletin for more details.

SOURCE: IHCP Bulletin: IHCP to Begin Enrollment for Telehealth-Only Providers BT202417 (Feb. 15, 2024). (Accessed Aug. 2024).

The practitioners listed in IC 25-1-9.5-3.5 are authorized to provide telehealth services under the scope of their licensure within the state of Indiana.

The IHCP will allow these practitioners to provide telehealth services and receive reimbursement for IHCP services, within the established IHCP billing rules and policies. Providers not on this list are not allowed to practice telehealth or receive IHCP reimbursement for such services, even under the supervision of one of these listed practitioners. Providers rendering services within the state of Indiana are encouraged to have a telehealth provider certification filed with the Indiana Professional Licensing Agency. Providers rendering services out of state are required to have a telehealth provider certification under IC 25-1-9.5-9; see the Out-of-State Telehealth Providers section for more information.

NOTE: Not all practitioners that are authorized to provide telehealth services are allowed to enroll as rendering providers in the IHCP. Those that are not eligible for IHCP enrollment must bill under the IHCP-enrolled supervising practitioner’s National Provider Identifier (NPI), using the appropriate modifiers (as applicable). The rendering NPI entered on the claim must be enrolled under a specialty that is allowable for telehealth.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 2, (Accessed Aug. 2024).

For a provider to be reimbursed for telehealth services under the IHCP, the provider must be enrolled with the IHCP and be a licensed practitioner listed in IC 25-1-9.5-3.5. Providers rendering services in state are also encouraged to have a telehealth provider certification filed with the Indiana Professional Licensing Agency. Providers rendering services out of state are required to have a telehealth provider certification under IC 25-1-9.5-9.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). (Accessed Aug. 2024).

The IHCP will allow these providers to provide telehealth services and receive reimbursement for IHCP services, within the established IHCP billing rules and policies:

A behavior analyst licensed under IC 25-8.5
A chiropractor licensed under IC 25-10
A dental hygienist licensed under IC 25-13*
The following:
- A dentist licensed under IC 25-14
- An individual who holds a dental residency permit issued under IC 25-14-1-5*
- An individual who holds a dental faculty licensed under IC 25-14-1-5.5*
A diabetes educator licensed under IC 25-14.3*
A dietitian licensed under IC 25-14.5*
A genetic counselor licensed under IC 25-17.3
The following:
- A physician licensed under IC 25-22.5
- An individual who holds a temporary medical permit under IC 22-22.5-5-4*
A nurse licensed under IC 25-23*
An occupational therapist licensed under IC 25-23.5
Any behavioral health and human services professional licensed under IC 25-23.6
An optometrist licensed under IC 25-24
A pharmacist licensed under IC 25-26*
A physical therapist licensed under IC 25-27
A physician assistant licensed under IC 5-27.5
A podiatrist licensed under IC 25-29
A psychologist licensed under IC 25-33
A respiratory care practitioner licensed under IC 25-34.5*
A speech-language pathologist or audiologist licensed under IC 25-35.6

Some providers (within the licensure citations above) marked with an asterisk may not be able to enroll as rendering providers in the IHCP and must bill under the IHCP-enrolled supervising practitioner’s National Provider Identifier (NPI) using the appropriate modifiers (as applicable). In addition, providers not on this list are not allowed to practice telehealth and/or receive IHCP reimbursement for such services, even under the supervision of one of these listed practitioners.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202142, June 8, 2021, (Accessed Aug. 2024).

Providers that can deliver healthcare services via telehealth must be listed as an authorized practitioner in SB 3(SEA 3). Providers not listed as authorized practitioners in SB 3(SEA 3) are not permitted to practice telehealth and/or receive IHCP reimbursement for telehealth services, even under the supervision of one of these listed practitioners.

SOURCE: Indiana Health Coverage Programs (IHCP) Bulletin, BT202145, June 17, 2021. (Accessed Aug. 2024).

The office shall reimburse the following Medicaid providers for medically necessary telehealth services:

A federally qualified health center
A rural health clinic
A community mental health center
A critical access hospital
A home health agency licensed under IC 16-27-1.
A provider, as determined by the office to be eligible, providing a covered telehealth service.

SOURCE: IN Admin Code, “Article 5” 405 5-38-4(3) p. 199-200 & IN Code, 12-15-5-11. (Accessed Aug. 2024).

The office may not impose any distance restrictions on providers of telehealth activities or telehealth services. Subject to federal law, the office may not impose any location requirements concerning the originating site or distant site in which a telehealth service is provided to a Medicaid recipient.

SOURCE: IN Code, 12-15-5-11 (Accessed Aug. 2024).

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Special billing considerations apply for federally qualified health center (FQHC) and rural health clinic (RHC) providers. FQHC and RHC providers may bill for telehealth services if the service rendered is considered a valid FQHC or RHC encounter (as defined in the Federally Qualified Health Centers and Rural Health Clinics module) and a covered telehealth service (as defined by the Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers). Subject to the following criteria, reimbursement is available to FQHCs and RHCS when they are serving as either the distant site or the originating site for telehealth services.

Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 10, 11, 12, 31, 32, 50 or 72
One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 6, Indiana Health Coverage Programs, Federally Qualified Health Centers and Rural Health Clinics, p. 6 (May 7, 2024). (Accessed Aug. 2024).

A valid FQHC or RHC encounter is defined as a face-to-face visit (either in person or via telemedicine) between an IHCP member and a qualifying practitioner (see the Rendering Providers section) at an FQHC, RHC, or other qualifying, non-hospital setting.

SOURCE: Medicaid Federally Qualified Health Centers and Rural Health Clinics Module, Jan. 1, 2022 (published May 7, 2024), p. 4, (Accessed Mar. 2024).

Non-Eligible Providers

IHCP does not reimburse the following provider types for telemedicine:

Ambulatory surgical centers;
Outpatient surgical services;
Home health agencies or services (For information about home health agency reimbursement for telehealth services, see the Telehealth Services section);
Radiological services;
Laboratory services;
Long-term care facilities, including nursing facilities, intermediate care facilities, or community residential facilities for the developmentally disabled;
Anesthesia services or nurse anesthetist services;
Audiological services;
Chiropractic services;
Care coordination services;
Durable medical equipment, and home medical equipment providers
Optical or optometric services;
Podiatric services;
Physical therapy services;
Transportation services;
Services provided under a Medicaid home and community-based services waiver.
Provider to provider consultations

SOURCE: IN Admin. Code, “Article 5” Title 405, 5-38-4, p. 200 (Accessed Aug. 2024).

ELIGIBLE SITES

Telehealth services may be rendered in an inpatient, outpatient or office setting. The provider and/or patient may be located in their home during the time of these services. For IHCP reimbursement of telehealth services, the member must be physically present at the originating site and must participate in the visit.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p.1 , (Accessed Aug. 2024).

SOURCE: IN Code, 12-15-5-11 (Accessed Aug. 2024).

Per Indiana Code IC 25-1-9.5-3, “originating site” means any site at which a patient is located at the time healthcare services through telehealth are provided to the individual. Accordingly, eligible providers may be reimbursed for procedure code Q3014 when the provider location is acting as an originating site for telehealth services.

SOURCE: ICHP Expands Procedure Code Q3014 to Additional Providers BT 202332 (Apr. 25, 2023). (Accessed Aug. 2024).

Separate reimbursement for a provider at the originating site is payable only if that provider’s presence is medically necessary. Adequate documentation must be maintained in the patient’s medical record to support the need for the provider’s presence at the originating site during the visit. Such documentation is subject to post-payment review. If a healthcare provider’s presence at the originating site is medically necessary, billing of the appropriate evaluation and management code is permitted.

SOURCE: IN Admin. Code, “Article 5” Title 405, 5-38-4, p. 199 (Accessed Aug. 2024).

GEOGRAPHIC LIMITS

SOURCE: IN Code 12-15-5-11 (Accessed Aug. 2024)

Medicaid may not require:

A provider that is licensed, certified, registered, or authorized with the appropriate state agency or board and exclusively offers telehealth services (as defined in IC 12-15-5-11(a)) to maintain a physical address or site in Indiana to be eligible for enrollment as a Medicaid provider.
A telehealth provider group with providers that are licensed, certified, registered, or authorized with the appropriate state agency or board to have an in-state service address to be eligible to enroll as a Medicaid vendor or Medicaid provider group.

SOURCE: IN Code 12-15-11-10 (Accessed Aug. 2024).

FACILITY/TRANSMISSION FEE

If the member is located in a medical facility (such as a hospital, clinic or physician’s office) while receiving the telehealth service, and it is medically necessary for a medical professional to be physically present with the member during the service, the IHCP covers Healthcare Common Procedure Coding System (HCPCS) code Q3014 – Telehealth originating site facility fee, billed with modifier 95, for the provider e at the originating site.

If the originating site is a hospital or other location that bills on an institutional claim, HCPCS code Q3014 is reimbursable when billed with revenue code 780 – Telemedicine – General. If a different, separately reimbursable treatment room revenue code is provided on the same day as the telehealth service, the appropriate treatment room revenue code should also be included on the claim. Documentation must be maintained in the patient’s record to indicate that services were provided separately from the telehealth visit.

If the originating site is a physician’s office, clinic or other location that bills on a professional claim, POS code 02 must be used for Q3014, along with modifier 95. If other services are provided on the same date as the telehealth service, the medical professional should bill Q3014 as a separate line item from other professional services.

If the originating site is an FQHC or RHC, additional billing requirements apply. See the Telehealth Services for FQHCs and RHCs section.

SOURCE: Indiana Health Coverage Programs, Telehealth and Virtual Services, Provider Reference Module (Feb. 29, 2024), p. 5. (Accessed Aug. 2024).

Effective immediately, and retroactive to dates of services (DOS) on or after July 21, 2022, the following specialties under provider type 11 – Behavioral Health Provider will be able to receive reimbursement for procedure code Q3014 when their offices or facilities are acting as an originating telehealth site for members:

616 – Licensed Psychologist
617 – Licensed Independent Practice School Psychologist
618 – Licensed Clinical Social Worker (LCSW)
619 – Licensed Marriage and Family Therapist (LMFT)
620 – Licensed Mental Health Counselor (LMHC)
621 – Licensed Clinical Addiction Counselor (LCAC)

SOURCE: ICHP Expands Procedure Code Q3014 to Additional Providers BT 202332 (Apr. 25, 2023). (Accessed Aug. 2024).

When the FQHC or RHC is the originating site (the location where the patient is physically located), the FQHC or RHC may be reimbursed if it is medically necessary for a medical professional to be present with the member, and the service provided includes all components of a valid encounter code. The claim must include the following:

Encounter code T1015 (or D9999 for valid dental encounters), billed with POS code 02, 03, 04, 11, 12, 31, 32, 50 or 72
Procedure code Q3014 – Telehealth originating site facility fee, billed with POS code 02 and modifier 95
One or more appropriate procedure codes for the specific services rendered, billed with modifier 93 or 95, and a POS code of either 02 or 10, depending on the originating site/location of the patient

Note: The procedure code must appear on one of the code tables in this bulletin, and must be on the list of procedure codes allowable for an FQHC/RHC medical or dental encounter.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202239 (May 19, 2022). IHCP Bulletin BT 202253 (July 14, 2022). (Accessed Aug. 2024).

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Iowa

Last updated 08/26/2024

POLICY

An in-person contact between a health care professional and …

POLICY

An in-person contact between a health care professional and a patient is not required as a prerequisite for payment for otherwise-covered services appropriately provided through telehealth in accordance with generally accepted health care practices and standards prevailing in the applicable professional community at the time the services are provided, as well as being in accordance with provisions under rule 653—13.11(147,148,272C). Health care services provided through in-person consultations or through telehealth shall be treated as equivalent services for the purposes of reimbursement

SOURCE: IA Admin Code Sec. 441, 78.55 (249A). (Accessed Aug. 2024).

Based on this rule [see above], there is no additional payment for the telehealth components of service, associated with the underlying service being rendered. Payment for a service rendered via telehealth is the same as payment made for that service when rendered in a face-to-face (i.e., in-person) setting.

SOURCE: IA Dep. of Human Services. Informational Letter No. 1815-MC-FFS, Aug. 10, 2017, (Accessed Aug. 2024).

Crisis Response Services and Subacute Mental Health Services.

“Face-to-face” means services in-person or using telehealth in conformance with the federal Health Insurance Portability and Accountability Act (HIPAA) privacy rules.

SOURCE: Iowa Dep. of Human Services. Provider Manual. Ch. III Provider Specific Policies. Crisis Response Services, p. 19, May 1, 2018; IA Admin Code Sec. 441-24.20; Subacute Mental Health Services. May 1, 2018, p. 9. (Accessed Aug. 2024).

ELIGIBLE SERVICES/SPECIALTIES

See approved procedure code list.

SOURCE: IA Medicaid. New Telehealth Approved Codes [see quarterly codes dropdown], 8/8/24, (Accessed Aug. 2024).

Please visit the Iowa Medicaid PHE unwind webpage for telehealth service codes continuing post-PHE. The effective date for the discontinued telehealth service codes is December 31, 2023. After this date, claims submitted with discontinued service codes, when billed as telehealth (place of service 02 or 10), will be denied.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2457-MC-FFS, Jun. 2, 2023 (Effective Dec. 31, 2023), (Accessed Aug. 2024).

IA Medicaid covers teledentistry synchronous real time encounter.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2124-MC-FFS, April 6, 2020, (Accessed Aug. 2024).

Please be aware that while some services such as teledentistry will continue after the PHE, billing requirements for some other services provided via telehealth may change when the PHE is lifted.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2323-MC-FFS, Mar. 11, 2022 (Effective April 1, 2023), (Accessed Aug. 2023).

Pursuant to the authority of Iowa Code section 249A.4, HHS has amended the 1915(C) HCBS AIDS/HIV, Brain Injury (BI), Health and Disability (HD), Intellectual Disability (ID) and Physical Disability (PD) Waivers. The Centers for Medicaid and Medicare services approved these amendments on April 23, 2024, retroactive to November 1, 2023. As part of the amendments the Department has made the changes listed below to the waivers. …

“Telehealth” means the delivery of SCL services using real-time interactive audio and video, or other real-time interactive electronic media, regardless of where the health care professional and the covered person are each located.
“Telehealth” does not include the delivery of health care services delivered solely through an audio-only telephone, electronic mail message or facsimile transmission.
See letter for list of eligible codes.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2588-MC-FFS, June 4, 2024, (Accessed Aug. 2024).

ELIGIBLE PROVIDERS

The following providers may serve as the distant site provider:

Physicians
Nurse Practitioners
Physician Assistants
Nurse-Midwives
Clinical Nurse Specialists
Certified Registered Nurse Anesthetists
Clinical Psychologists
Clinical Social Workers
Federally Qualified Health Centers
Behavioral Health Service Providers
- Licensed Independent Social Workers
- Licensed Master Social Workers
- Licensed Marital and Family Therapists
- Licensed Mental Health Counselors
- Certified Alcohol and Drug Counselors

SOURCE: Iowa Dep. of Human Services. Informational Letter No. 2103-MC-FFS. (Feb. 20, 2020). (Accessed Aug. 2024).

ELIGIBLE SITES

All services delivered via telehealth must be billed with one of the following POS codes:

02 – telehealth provided other than in the patient’s home
- The location where health services and health-related services are provided or received, through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.
10 – telehealth provided in the patient’s home
- The location where health services and health-related services are provided or received through telecommunication technology. The patient is in their home (which is a location other than a hospital or other facility where the patient receives care) when receiving health services or health related services through telecommunication technology.

As announced in IL 24573, claims submitted with service codes not included in the telehealth approved list continuing post-Public Health Emergency (PHE) and billed as telehealth (Place of service 02 or 10) after December 31, 2023 will be denied.

SOURCE: Iowa Dep. of Human Services. Informational Letter No. 2472-MC-FFS. (Sept. 11, 2023). (Accessed Aug. 2024).

The following locations may serve as the originating site:

The offices of physicians and other practitioners (psychologists, social workers, behavioral health providers, habilitation services providers, and advanced registered nurse practitioners (ARNPs)).
Hospitals
Critical Access Hospitals
Community Mental Health Centers
Federally Qualified Health Centers
Rural Health Clinics
Area Education Agencies (AEAs) and Local Education Agencies

SOURCE: Iowa Dep. of Human Services. Informational Letter No. 2103-MC-FFS. (Feb. 20, 2020). (Accessed Aug. 2024).

For the purpose of this provision, a “facility” place of service (POS) is defined as any of the following (consistent with “POS” definitions under Medicare, per the Medicare Claims Processing Manual, Chapter 12, Section 20.4.2, revised as of May 2017):

Telehealth (POS 02).

SOURCE: IA Statute 441.79.1, (Accessed Aug. 2024).

The Centers for Medicare and Medicaid (CMS) has added a new POS for telehealth to identify when individuals are receiving services via telehealth in their homes. Iowa Medicaid will adopt this POS effective April 1, 2022. The provider will bill the applicable Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes with POS code 02 (telehealth) if the member is receiving services anywhere other than home. The provider will bill the applicable HCPCS/CPT codes with POS code 10 (telehealth patient in home) if the member is in their home. An originating site charge will not be applicable with a POS code 10. However, a distant site charge may be applicable.

POS 02: Telehealth Provided Other than in Patient’s Home Descriptor: The location where health services and health-related services are provided or received, through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.
POS 10: Telehealth Provided in Patient’s Home Descriptor: The location where health services and health-related services are provided or received through telecommunication technology. The patient is located in their home (which is a location other than a hospital or other facility where the patient receives care) when receiving health services or health related services through telecommunication technology.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2323-MC-FFS, Mar. 11, 2022 (Effective April 1, 2023), (Accessed Aug. 2024).

Effective March 13, 2020, the site of service differential was removed from place of service 02 (please refer to Informational Letter 1815-MC-FFS2 [see below). As discussed during the April 27, 2023, provider town hall event, the site of service differential with the place of service 02 and 10 will not be applied to telehealth claims.

SOURCE: IA Dep. of Human Services. Informational Letter No. 2457-MC-FFS, Jun. 2, 2023 (Effective Dec. 31, 2023), (Accessed Aug. 2024).

POS code 02 is defined as, “the location where health services and health related services are provided or received, through a telecommunication system”. POS code 02 is used to report that a billed service was furnished as a telehealth service from a distant site. The only portion that is considered telehealth services is when the patient was present and interacting with the distant site physician or practitioner.

An originating site is the location of a Medicaid member at the time the telehealth service is furnished. CMHCs can be an originating site. Other originating sites can include: physician offices, hospitals, and critical access hospitals (CAHs). The “telehealth” POS code (i.e., “02”) would not be used by an originating site that can bill a facility fee (i.e., Q3014), instead the originating site would continue to use the POS code that applies to the type of facility where the patient is located. Under these circumstances, a CMHC would bill POS 53 (CMHC).

CMHCs billing for services under the CMHC provider category will not have payments cut back for the SoS differential, in cases where the service is provided at POS 02 (Telehealth). Consistent with the immediately preceding paragraph, the “distant” provider would bill POS 02 for the telehealth service and the CMHC would bill POS 53. In these cases, under Medicaid, there is no separate facility bill to account for the overhead, and therefore no SoS cut would be taken, consistent with the intent of this policy.

SOURCE: IA Dep. of Human Services. Informational Letter No. 1815-MC-FFS, Aug. 10, 2017, (Accessed Aug. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating sites are paid a facility fee for telehealth services. FQHCs and RHCs would not bill Q3014 as a separate service because reimbursement for the related costs would occur through the annual cost settlement process.

SOURCE: Iowa Dep. of Human Services. Informational Letter No. 2103-MC-FFS. (Feb. 20, 2020). (Accessed Aug. 2024).

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Kansas

Last updated 07/03/2024

POLICY

No individual or group health insurance policy, medical service …

POLICY

No individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society, health maintenance organization or the Kansas medical assistance program shall exclude an otherwise covered healthcare service from coverage solely because such service is provided through telemedicine, rather than in-person contact, or based upon the lack of a commercial office for the practice of medicine, when such service is delivered by a healthcare provider.

SOURCE: KS Statute Ann. § 40-2,213(b). (Accessed Jul. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Office visits, individual psychotherapy, and pharmacological management services are examples of services which may be reimbursed when provided via telecommunication technology. The provider at the distant side must bill an appropriate code from the lists below with place of service (02) designating a telemedicine service provided other than in the patient’s home OR place of service (10) designating a telemedicine service provided in the patient’s home. (Please note: the GT modifier is no longer used to designate a telemedicine service.) Services delivered via telemedicine will be reimbursed at the same rate as a face-to-face (in the same physical location) service. Documentation requirements are the same as an in-person service.

See manual for eligible codes.

QMB only codes are not noted in these tables. Additionally, telemedicine rules governing HCBS waiver codes may change depending on waiver submissions; therefore, the specific HCBS waiver manual needs to be consulted for current code status allowances.

KMAP does not recognize AMA CPT consultation codes 99242, 99243, 99244, 99245, 99252, 99253, 99254, and 99255 for payment.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, (May 2024), pg. 2-28, (Accessed Jul. 2024).

Note: Refer to Section 2720 of the General Benefits Fee-for-Service Provider Manual for complete details regarding Telemedicine.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, FQHC/RHC, p. 8-14 (May 2024); Provider Manual, Substance Use Disorder, p. A-2, (May. 2024); Early Childhood Intervention, (May 2024), pg. 8-5; Local Education Agency (Jun. 2024), pg. 8-7; Provider Manual, Certified Community Behavioral Health Clinic (CCBHC), p. 8-5 (May 2024); Home Health Agency, p. 8-29 (May 2024), Mental Health, p. 8-18, 8-19, 8-29, A-II, (Jun. 2024), Rehabilitative Therapy Services, (May 2024), pg. 8-5, (Accessed Jul. 2024).

Stand-alone vaccine counseling may also be covered when provided via telehealth.

The face-to-face encounter [for home health] may occur through telehealth, as implemented by the State.

Telehealth and transportation codes are covered codes for OTP services. Please refer to the Kansas Medicaid Telehealth and Non-Emergency Medical Transportation (NEMT) policies

SOURCE: KS Dept. of Health and Environment, Provider Manual, Professional, (Jul. 2024). (Accessed Jul. 2024).

Stand-alone vaccine counseling will be covered only when the vaccine counseling and the administration of the vaccine occurs on two separate visits. Vaccine counseling is content of service when the vaccine counseling and administration of the vaccine occur at the same visit. Stand-alone vaccine counseling may also be covered when provided via telehealth.

SOURCE: KS Dept. of Health and Environment, Provider Manual, KAN Be Health EPSDT, (6/24), (Accessed Jul. 2024).

Autism Services

Family Adjustment Counseling Limitations – Delivery of this service may occur via telemedicine, telehealth, or other modes of video distance monitoring methods that adhere to all required HIPAA guidelines and meet the state standards for telemedicine delivery methods. This service delivery model is subject to state program manager approval. A request submitted for this exception must include, at a minimum, three written statements from service providers in at least a 50-mile radius declining to provide services because the participant resides in a location that is so remote or far away that the provider does not have the staff to meet with the child on a continual and/or intermittent basis as needed.

Parents Support and Training – Delivery of this service may occur via telemedicine, telehealth, or other modes of video distance monitoring methods that adhere to all required HIPAA guidelines and meet the state standards for telemedicine delivery methods. This service delivery model is subject to state program manager approval. A request submitted for this exception must include, at a minimum, three written statements from service providers in at least a 50-mile radius declining to provide services because the participant resides in a location that is so remote or far away that the provider does not have the staff to meet with the child on a continual and/or intermittent basis as needed.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, HCBS Autism Services, p. 8-5 & 8-9 (Aug. 2023). (Accessed Jul. 2024).

Intellectual/Developmentally Disabled Services

All functional assessments must be conducted in-person at a location of the individual’s choosing, or, if available, through the use of real-time interactive telecommunications equipment that includes, at a minimum, audio and video equipment. Those responsible for conducting the assessment will be flexible in accommodating the individual’s preference for the meeting location and time of assessment.

SOURCE: KS Dept. of Health and Environment, Provider Manual, HCBS Intellectual/Developmentally Disabled, p. I-1 (Jun. 2024). (Accessed Jul. 2024).

Prenatal Care At Risk Enhanced Care Coordination

Effective with dates of service on and after May 1, 2023, procedure code H1002 will be covered for telemedicine for video and audio transmissions. Existing provisions for the delivery of this service will remain in effect. Place of service (POS) code 10 (telehealth services provided in patient’s home) will be covered for code H1002.

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23051, Prenatal Care At Risk Enhanced Care Coordination, Mar. 2023, (Accessed Jul. 2024).

Lactation Counseling

Effective with dates of service on or after April 1, 2023, lactation counseling services (utilizing procedure code S9443) for nonphysician lactation counselors will be additionally covered via telemedicine. Both video and audio transmissions will be covered. The home setting is allowed for this service delivery. Existing provisions for the delivery of this service will remain in effect until specifically rescinded.

Telemedicine Place of Service (POS) codes include:

02 – Telehealth
10 – Telehealth in patient home

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23042, Lactation Counseling Via Telemedicine, Feb. 2023, (Accessed Jul. 2024).

HCBS Appendix K

The service delivery options that will continue after November 11 include the following: …

A Remote Option for Receiving Services:

Members will be able to receive some in-home services through tele-video. The State is currently working to receive approval from the federal government for this. Managed Care Organization (MCO) Care Coordinators will provide members more information when this option is approved.

SOURCE: KMAP General Bulletin 23302 HCBS Appendix K – COVID Measure Rescinding (PHE Changes Ending), Nov. 2023, (Accessed Jul. 2024).

Non-Waiver Mental Health Attendant Care Service

Telehealth services are excluded from the EVV process for Non-Waiver Mental Health Attendant Care. Centers will continue to submit claims for Non-Waiver Mental Health Attendant Care until otherwise instructed.

SOURCE: KMAP General Bulletin 23326 Non-Waiver Mental Health Attendant Care Service Code – EVV Implementation Resuming, Dec. 2023, (Accessed Jul. 2024).

Advance Directives

The face-to-face encounter may occur through telehealth, as implemented by the State.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, (May 2024), pg. 8-7. (Accessed Jul. 2024).

Serious Emotional Disturbances

Wraparound Facilitation: Meetings can be telehealth or by conference call by member’s choice when the meeting is not the initial or 6-month review.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, HCBS Serious Emotional Disturbances (SED), (Apr. 2023), pg. 7-6. (Accessed Jul. 2024).

Medication Assisted Treatment

Telehealth and transportation codes are covered codes for OTP services. Please refer to the Kansas Medicaid Telehealth and Non-Emergency Medical Transportation (NEMT) policies.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Mental Health, (Jun. 2024), pg. 8-15; & Substance Use Disorder Provider Manual, (May 2024), pg. 7-6. (Accessed Jul. 2024).

ELIGIBLE PROVIDERS

Provisions in the Kansas Telemedicine Act will allow speech-language pathologists and audiologists licensed by KDADS to provide services via telemedicine. Services must be provided via real-time, interactive (synchronous) audio-video telecommunication equipment that is compliant with HIPAA.

Note: See specific Telemedicine code allowances and guidelines under Section 2720 of this manual.

The provider at the distant side must bill an appropriate code from the lists below with place of service (02) designating a telemedicine service provided other than in the patient’s home OR place of service (10) designating a telemedicine service provided in the patient’s home. (Please note: the GT modifier is no longer used to designate a telemedicine service.) Services delivered via telemedicine will be reimbursed at the same rate as a face-to-face (in the same physical location) service. Documentation requirements are the same as an in-person service.

“Distant site” means a site at which a healthcare provider is located while providing healthcare services by means of telemedicine.

“Healthcare provider” means an individual appropriately licensed, registered, certified, or otherwise authorized to provide a specifically designated telemedicine service.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, (May 2024), pg. 2-27 to 29, (Accessed Jul. 2024).

ELIGIBLE SITES

The originating site provider, with the patient present, may bill Q3014 with the appropriate place of service code denoted.

Codes S9453 and T2011 are allowed but not in the home.

“Originating site” means a site at which a patient is located at the time healthcare services are provided by means of telemedicine.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, General Benefits, (May 2024), pg. 2-27 to 29, (Accessed Jul. 2024).

Effective with dates of service on and after July 24, 2024, one of the following Place of Service (POS) codes should be utilized for all visits in AuthentiCare: …

02: Telehealth Provided Other than in Patient’s Home …
10: Telehealth Provided in Patient’s Home

SOURCE: KS KMAP General Medicaid Bulletin 24100, Jul. 2024, (Accessed Jul. 2024).

Adding Place of Service Code 10 to Home Telehealth Nursing Services

Effective with dates of processing on and after January 1, 2022, licensed practical nurses (LPNs) or registered nurses (RNs) that provide home telehealth services must use Place of Service (POS) code 10 for codes T1030 and T1031 on all claims.

SOURCE: KS Department of Health and Environment, KMAP Bulletin 23033, Adding Place of Service Code 10 to Home Telehealth Nursing Services, Feb. 2023, (Accessed Jul. 2024).

See remote patient monitoring section for more information on home telehealth services from the Home Health Agency Manual.

Intensive Individual Support (IIS) Providers

Intensive Individual Support (IIS) providers may now bill under the following POS codes:…

02 – Telehealth Provided Other Than in Patients Home
10 – Telehealth Provided in Patients Home

See bulletin for other POS codes.

SOURCE: KS KMAP General Medicaid Bulletin 23211, Aug. 2023, (Accessed Jul. 2024).

CCBHC

The allowable Place of Service (POS) codes for HCPCS code H0040 are defined to provide clarity on coverage:

02 – Telehealth Provided Other Than in Patients Home
10 – Telehealth Provided in Patients Home

SOURCE: KS KMAP General Medicaid Bulletin 24005, Jan. 2024, (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Certified Community Behavioral Health Clinic (CCBHC) Services

The originating site, with the member present, may bill code Q3014 with the appropriate POS code. No payment will be made for Q3014 if the originating telemedicine site is place of service “home” (POS code 12) without the physical presence of a provider.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, FFS Provider Manual, Certified Community Behavioral Health Clinic (CCBHC) Services, (May 2024). (Accessed Jul. 2024).

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Kentucky

Last updated 07/08/2024

POLICY

The department must reimburse an eligible telehealth care provider …

POLICY

The department must reimburse an eligible telehealth care provider for a telehealth service in an amount that is at least 100 percent of the amount for a comparable in-person service. A managed care plan may establish a different rate for telehealth reimbursement via contract.

Any recipient, upon being offered the option of an asynchronous or audio-only telehealth visit, shall have the opportunity or option to request to be accommodated by that provider in an in-person encounter or synchronous telehealth encounter.

A telehealth care provider that has received a request for an in-person encounter or synchronous telehealth encounter shall provide an alternative in-person or synchronous telehealth encounter for the recipient within:

A reasonable time;
The existing availability constraints of the provider’s schedule; and
No more than three (3) weeks of the recipient’s request, unless the recipient’s condition or described symptoms suggest a need for an earlier synchronous or in-person encounter.

A provider’s failure to accommodate a recipient with a synchronous telehealth or in-person encounter shall be reported to the Office of the Ombudsman and Administrative Review of the Cabinet for Health and Family Services, or its successor organization by a:

Recipient;
Recipient’s guardian or representative;
Another provider; or
Managed care organization.

The Office of the Ombudsman and Administrative Review shall investigate as appropriate and forward reports of a failure to accommodate to the department.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Jul. 2024).

A request for reimbursement shall not be denied solely because:

An in-person consultation between a Medicaid-participating practitioner and a patient did not occur; or
A Medicaid-participating provider employed by a rural health clinic, federally qualified health center, or federally qualified health center look-alike was not physically located on the premises of the clinic or health center when the telehealth service or telehealth consultation was provided.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Jul. 2024).

In accordance with KRS 211.336, the Department for Medicaid Services and any managed care organization with whom the department contracts for the delivery of Medicaid services shall not:

Require a Medicaid provider to be physically present with a Medicaid recipient, unless the provider determines that it is medically necessary to perform those services in person;
Require prior authorization, medical review, or administrative clearance for telehealth that would not be required if a service were provided in person;
Require a Medicaid provider to be employed by another provider or agency in order to provide telehealth services that would not be required if that service were provided in person;
Require demonstration that it is necessary to provide services to a Medicaid recipient through telehealth;
Restrict or deny coverage of telehealth based solely on the communication technology or application used to deliver the telehealth services; or
Require a Medicaid provider to be part of a telehealth network.

Nothing in this section shall be construed to require the Medicaid program or a Medicaid managed care organization to:

Provide coverage for telehealth services that are not medically necessary; or
Reimburse any fees charged by a telehealth facility for transmission of a telehealth encounter.

The cabinet, in implementing Sections 2 and 3 of this Act, shall maintain telehealth policies and guidelines to providing care that ensure that Medicaid-eligible citizens will have safe, adequate, and efficient medical care, and that prevent waste, fraud, and abuse of the Medicaid program.

SOURCE: KY Revised Statute Sec. 205.5591, (Accessed Jul. 2024).

As appropriate for the service, provider, and recipient, utilize the following modalities of communication delivered over a secure communications connection that complies with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Live or real-time audio and video synchronous telehealth technology;
Asynchronous store-and-forward telehealth technology;
Remote patient monitoring using wireless devices, wearable sensors, or implanted health monitors;
Audio-only telecommunications systems; or
Clinical text chat technology if:
- Utilized within a secure, HIPAA compliant application or electronic health record system; and

- Meeting:
  - The scope of the provider’s professional licensure; and
  - The scope of practice of the provider; and
Comply with the following federal laws to prevent waste, fraud, and abuse relating to telehealth:
- False Claims Act, 31 U.S.C. § 3729-3733;
- Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b); and
- Physician Self-Referral, Section 1877 of the Social Security Act

SOURCE: KY 900 KAR 12:005 (Accessed Jul. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The Cabinet for Health and Family Services and any managed care organization with whom the Department for Medicaid Services contracts for the delivery of Medicaid services shall provide Medicaid reimbursement for covered telehealth services and telehealth consultations, if the telehealth service or telehealth consultation:

Is provided by a Medicaid-participating practitioner, including those employed by a home health agency licensed pursuant to KRS Chapter 216, to a Medicaid recipient or another Medicaid-participating practitioner at a different physical location; and
Meets all clinical, technology, and medical coding guidelines for recipient safety and appropriate delivery of services established by the Department for Medicaid Services or the provider’s professional licensure board.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Jul. 2024).

Telehealth service means any service that is provided by telehealth that is one of the following:

Event
Encounter
Consultation, including a telehealth consultation
Visit
Store-and-forward transfer, as limited by Section 6
Remote patient monitoring
Referral
Treatment

A telehealth service shall not be reimbursed by the department if:

It is not medically necessary;
The equivalent service is not covered by the department if provided in an in-person setting; or
The telehealth care provider of the telehealth service is:
- Not currently enrolled in the Medicaid Program pursuant to 907 KAR 1:672;
- Not currently participating in the Medicaid Program pursuant to 907 KAR 1:671;
- Not in good standing with the Medicaid Program;
- Currently listed on the Kentucky DMS Provider Terminated and Excluded Provider List, which is available at https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/terminated.aspx;
- Currently listed on the United States Department of Health and Human Services, Office of Inspector General List of Excluded Individuals and Entities, which is available at https://oig.hhs.gov/exclusions/;
- Otherwise prohibited from participating in the Medicaid program in accordance with 42 C.F.R. Part 455; or
- Not physically located within the United States or a United States territory at the time of service.

A telehealth service shall be subject to utilization review for:

Medical necessity;
Compliance with this administrative regulation; and
Compliance with applicable state and federal law.

The department shall not reimburse for a telehealth service if the department determines that a telehealth service is not:

Medically necessary:
Compliant with this administrative regulation;
Applicable to this administrative regulation; or
Compliant with applicable state or federal law.

The department shall recover the paid amount of a reimbursement for a previously reimbursed telehealth service if the department determines that a telehealth service was not:

Medically necessary;
Compliant with this administrative regulation;
Applicable to this administrative regulation; or
Compliant with applicable state or federal law.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Jul. 2024).

If, after reviewing the allegations contained in the petition and examining the petitioner under oath, it appears to the court that there is probable cause to believe the respondent should be ordered to undergo treatment, then the court shall: …

Cause the respondent to be examined no later than twenty-four (24) hours before the hearing date by two (2) qualified health professionals, at least one (1) of whom is a physician. The qualified health professionals: …
- May conduct the examination required by this paragraph via telehealth as defined in KRS 211.332.

SOURCE: KY Statute Sec. 222.433, (Accessed Jul. 2024).

Dental

“Direct practitioner interaction” means the billing dentist or oral surgeon is physically present with and evaluates, examines, treats, or diagnoses the recipient, unless the service can be appropriately performed via telehealth pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 1:126, (Accessed Jul. 2024).

Specialized Children’s Services Clinics

Certain services, such as crisis intervention, intensive outpatient program services, behavioral health therapeutic intervention, group outpatient therapy, family outpatient therapy, and peer support services consist of a one-on-one encounter between the provider and recipient conducted in-person or via telehealth as appropriate pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 3:160, (Accessed Jul. 2024).

Rural Health Clinic

Psychological testing, crisis intervention, service planning, individual outpatient therapy, family outpatient therapy, group outpatient therapy, collateral outpatient therapy, screening, brief intervention and refers to treatment for a substance use disorder, partial hospitalization, withdrawal management services, shall:…

Be in-person or via telehealth as appropriate pursuant to 907 KAR 3:170

Medication assisted treatment supporting behavioral health services shall Be colocated within the same practicing site as the practitioner who maintains a current waiver, as necessary, under 21 U.S.C. 823(g)(2) to prescribe buprenorphine products or via telehealth as appropriate pursuant to 907 KAR 3:170.

SOURCE: KY Admin Regs. Title 907 KAR 1:082, (Accessed Jul. 2024).

Treatment of Stuttering

The coverage required under subsection (2) of this section shall … Include coverage for speech therapy provided in person and via telehealth.

The telehealth coverage required under this paragraph shall:

Not be less than the coverage required for health benefit plans under KRS 304.17A-138; and
Include the use of any communication technology, application, or platform to deliver telehealth services, except coverage may be restricted to technology, applications, or platforms that are compliant with any applicable privacy provisions of the federal Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. sec. 1320d et seq., as amended.

SOURCE: Senate Bill 111 (2024 Session), (Accessed Jul. 2024).

“In-home program” means a program offered by a health care facility or health care professional for the treatment of substance use disorder which the insured accesses through telehealth or digital health service;

The Department for Medicaid Services and any managed care organization with which the department contracts for the delivery of Medicaid services shall provide coverage: …

For telehealth or digital health services that are related to maternity care associated with pregnancy, childbirth, and postpartum care.

The coverage required by this section shall: … For lactation consultation, include: …

The delivery of consultation via telehealth, as defined in KRS 205.510, if the beneficiary requests telehealth consultation in lieu of in-person, one-on-one consultation

SOURCE: KY Revised Statute 205.556, & SB 74 (2024 Session), (Accessed Aug. 2024).

Participants in the HANDS program shall participate in the home visitation program through in-person face-to-face methods or through tele-service delivery methods. For the purposes of this subsection, “teleservice” means a home visitation service provided through video communication with the HANDS provider, parent, and child present in real time.

SOURCE: KY Revised Statute 211.690, & SB 74 (2024 Session), (Accessed Aug. 2024).

ELIGIBLE PROVIDERS

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall:

To the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec. 1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike; or
If the telehealth service or telehealth consultation provider is employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike, include a supplemental reimbursement paid by the Department for Medicaid Services in an amount equal to the difference between the actual reimbursement amount paid by a Medicaid managed care organization and the amount that would have been paid if reimbursement had been made directly by the department.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Jul 2024).

A “telehealth care provider” is a Medicaid provider who is:

Currently enrolled as a Medicaid provider;
Currently participating as a Medicaid provider;
Operating within the scope of the provider’s professional licensure; and
Operating within the provider’s scope of practice; or

A community mental health center (CMHC) that is participating in the Medicaid program in compliance with 907 KAR 1:045, or 907 KAR 1:047.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Jul. 2024).

ELIGIBLE SITES

“Place of service” means anywhere the patient is located at the time a telehealth service is provided, and includes telehealth services provided to a patient located at the patient’s home or office, or a clinic, school, or workplace.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Jul. 2024).

See Provider Billing Instructionsby Provider Type for Place of Service Codes information, including use of 02 for telehealth services and 10 for telehealth provided in a patient’s home. ThePhysician Services Provider Billing Instructionsalso include modifiers to be used by physicians with a speciality of teleradiology, including U2 for teleradiology in-state and U3 teleradiology out-of-state.

SOURCE: KY Medicaid Management Information System. Provider Billing Instructions. (Accessed Aug. 2024).

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall:

To the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec. 1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike; or
If the telehealth service or telehealth consultation provider is employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike, include a supplemental reimbursement paid by the Department for Medicaid Services in an amount equal to the difference between the actual reimbursement amount paid by a Medicaid managed care organization and the amount that would have been paid if reimbursement had been made directly by the department.

Notwithstanding any provision of law to the contrary, neither the Department for Medicaid Services nor a Medicaid managed care organization with whom the department has contracted for the delivery of Medicaid services shall require that a health professional, as defined in KRS 205.510, or medical group maintain a physical location or address in this state to be eligible for enrollment as a Medicaid provider if the provider or group exclusively offers services via telehealth as defined in KRS 211.332.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Jul. 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

For rural health clinics, federally qualified health centers, and federally qualified health center look-alikes, reimbursement for covered telehealth services and telehealth consultations shall:

To the extent permitted under federal law, include an originating site fee in an amount equal to that which is permitted under 42 U.S.C. sec.
1395m for Medicare-participating providers if the Medicaid beneficiary who received the telehealth service or telehealth consultation was physically located at the rural health clinic, federally qualified health center, or federally qualified health center look-alike at the time of service or consultation delivery and the provider of the telehealth service or telehealth consultation is not employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike; or
If the telehealth service or telehealth consultation provider is employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike, include a supplemental reimbursement paid by the Department for Medicaid Services in an amount equal to the difference between the actual reimbursement amount paid by a Medicaid managed care organization and the amount that would have been paid if reimbursement had been made directly by the department.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Jul. 2024).

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Louisiana

Last updated 06/04/2024

POLICY

Louisiana Medicaid only reimburses the distant site for services …

POLICY

Louisiana Medicaid only reimburses the distant site for services provided via telemedicine. Reimbursement for services provided by telemedicine/telehealth is at the same level as services provided in person.

The beneficiary’s clinical record must include documentation that the service was provided through the use of telemedicine/telehealth. NOTE: The distant site provider must be enrolled as a Louisiana Medicaid provider to receive reimbursement for covered services rendered to Louisiana Medicaid beneficiaries.

Medicaid covered services provided using telemedicine must be identified on claim submissions by appending the modifier “95” to the applicable procedure code and indicating the correct place of service, either POS 02 (other than home) or 10 (home). Both the correct POS and the -95 modifier must be present on the claim to receive reimbursement

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165-166 (as issued 6/27/22). (Accessed Jun. 2024).

Telemedicine/telehealth is the use of an interactive audio and video telecommunications system to permit real time communication between a distant site health care practitioner and the beneficiary. There is no restriction on the originating site (i.e., where the beneficiary is located) and it can include, but is not limited to, a healthcare facility, school, or the beneficiary’s home.

Medicaid covered services provided via telehealth/telemedicine shall be identified on claim submissions by appending the Health Insurance Portability and Accountability Act (HIPAA) of 1996 compliant place of service (POS) or modifier to the appropriate procedure code, in line with current policy

SOURCE: LA Admin. Code 50: Sec. 501 & 503, p. 36 (Accessed Jun. 2024).

The MCO shall reimburse the distant site provider for services provided via telemedicine/telehealth. Reimbursement for services provided by telemedicine/telehealth is at the same level as services provided in person.

The MCO shall require the provider to include in the enrollee’s clinical record documentation that the service was provided through the use of telemedicine/telehealth.

The distant site provider must be enrolled as a Louisiana Medicaid provider to receive reimbursement for covered services rendered to Louisiana Medicaid enrollees.

SOURCE: MCO Manual (updated 6/11/24), pg. 176, (Accessed Jun. 2024).

ELIGIBLE SERVICES/SPECIALTIES

The department shall periodically review policies regarding Medicaid reimbursement for telehealth services to identify variations between permissible reimbursement under that program and reimbursement available to healthcare providers under the Medicare program.

To the extent practicable, notwithstanding any other law to the contrary, after conducting a review provided for in Subsection A of this Section, the department may modify its administrative rules, policies, and procedures applicable to Medicaid reimbursement for telehealth services as necessary to provide for a reimbursement system that is comparable to that of the Medicare program for those services.

SOURCE: LA Statute RS 40:1255.2 (Accessed Jun. 2024).

When otherwise covered, services located in the Telemedicine appendix of the CPT manual, or its successor, may be reimbursed when provided by telemedicine/telehealth. In addition, other specified services may be reimbursed when provided by telemedicine/telehealth and these services are explicitly noted in this manual.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165. (as issued 6/27/22). (Accessed Jun. 2024).

In the event that the federal or state government declares an emergency or disaster, the Medicaid Program may temporarily cover services provided through the use of an interactive audio telecommunications system, without the requirement of video, if such action is deemed necessary to ensure sufficient services are available to meet beneficiaries’ needs.

SOURCE: LA Admin Code, Sec. 50:I.505, (Accessed Jun. 2024).

When otherwise covered, the MCO shall cover services located in the Telemedicine appendix of the CPT manual, or its successor, when provided by telemedicine/telehealth. In addition, the MCO shall cover other services provided by telemedicine/telehealth when indicated as covered via telemedicine/telehealth in Medicaid program policy. The MCO shall ensure adequate availability of telemedicine/telehealth during declared emergencies, disasters, and pandemics. Physicians and other licensed practitioners must continue to adhere to all existing clinical policy for all services rendered. Providing services through telemedicine/telehealth does not remove or add any medical necessity requirements.

SOURCE: MCO Manual (revised 6/11/24, pg. 176, (Accessed Jun. 2024).

Treatment-in-place ambulance services

Effective for dates of service on or after May 12, 2023, the Louisiana Medicaid Program provides coverage for initiation and facilitation of telehealth services by qualified Louisiana Medicaid enrolled ambulance providers.

SOURCE: LA Admin Code, Title 50, Part IX, Subpart 1, Ch. 13, Sec. 1301, p. 336 (Accessed Jun. 2024).

A physician directed treatment-in-place service is the facilitation of a telehealth visit by an ambulance provider.

Each paid treatment-in-place ambulance claim must have a separate and corresponding paid treatment-in-place telehealth claim, and each paid treatment-in-place telehealth claim must have a separate and corresponding paid treatment-in-place ambulance claim or a separate and corresponding paid ambulance transportation claim. Reimbursement for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident is not permitted.

SOURCE: LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 2/16/24), (Accessed Jun. 2024).

Payment of treatment-in-place ambulance services is restricted to those identified on the Physician Directed Ambulance Treatment-in-Place Fee Schedule and edit claims for non-payable procedure codes as follows:

If a treatment-in-place ambulance claim is billed with mileage, the entire claim document shall be denied;
If an unpayable procedure code, that is not mileage, is billed on a treatment-in-place ambulance claim, only the line with the unpayable code will be denied;
Claims for allowable telehealth procedure codes must be billed with procedure code G2021. The G2021 code shall be accepted, paid at $0.00, and used by the transportation provider to identify treatment-in-place telehealth services; and
As with all telehealth claims, providers must include POS identifier “02” or “10” and modifier “95” with their claim to identify the claim as a telehealth service. Providers must follow CPT guidance relative to the definition of a new patient versus an established patient.

See valid treatment in place ambulance claim modifier list.

If the beneficiary being treated-in-place has a real-time deterioration in their clinical condition necessitating immediate transport to an emergency department, as determined by the ambulance provider (i.e., EMT or paramedic), telehealth provider, or beneficiary, the ambulance provider cannot bill for both the treatment-in-place ambulance service and the transport to the emergency department. In this situation, the ambulance provider shall bill for the transport to the emergency department only. The transportation broker shall require ambulance providers to submit pre-hospital care summary reports when ambulance treatment-in-place and ambulance transportation claims are billed for the same beneficiary with the same date of service.

If a beneficiary is offered treatment-in-place services declines the services, ambulance providers should include procedure code G2022 on claims for ambulance transportation to an emergency department. Use of this informational procedure code is optional and does not affect the establishment of medical necessity of the service or reimbursement of the ambulance transportation claim. The G2022 code shall be accepted, paid at $0.00, and used by the transportation provider to identify beneficiary refusal of treatment-in-place services

Payment of the treatment-in-place services is restricted to those identified on the Treatment-in-Place Telehealth Services Fee Schedule.

SOURCE: MCO Manual (revised 6/11/24), pg. 88-89, & LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 2/16/24), (Accessed Jun. 2024).

Behavioral Health Services

Assessments, evaluations, individual psychotherapy, family psychotherapy, and medication management services [CPST allowed in Rehabilitation Services section and services allowed within intensive outpatient or outpatient treatment may be provided in Addiction Services section] may be reimbursed when provided via telecommunication technology when the following criteria is met:

The telecommunication system used by physicians and LMHPs must be secure, ensure member confidentiality, and be compliant with the requirements of the Health Insurance Portability and Accountability Act (HIPAA);
The services provided are within the practitioner’s telehealth scope of practice as dictated by the respective professional licensing board and accepted standards of clinical practice;
The member’s record includes informed consent for services provided through the use of telehealth;
Services provided using telehealth must be identified on claims submission using by appending the modifier “95” to the applicable procedure code and indicating the correct place of service, either POS 02 (other than home) or 10 (home). Both the correct POS and the 95 modifier must be present on the claim to receive reimbursement;
Assessments and evaluations conducted by an LMHP through telehealth should include synchronous, interactive, real-time electronic communication comprising both audio and visual elements unless clinically appropriate and based on member consent; and
Providers must deliver in-person services when telehealth is not clinically appropriate or when the member requests in-person services.
Group psychotherapy is only allowed via telehealth when utilized for Dialectical Behavioral Therapy (DBT) and must include synchronous, interactive, real-time electronic communication comprising of both audio and visual elements. [in Outpatient Services, Outpatient Therapy by Licensed Practitioners section only, not Addiction section)

Exclusions: Methadone admission visits conducted by the admitting physician within Opioid Treatment Programs are not allowed via telecommunication technology. [in Addiction section only].

LMHP’s providing assessments, evaluations, individual psychotherapy, family psychotherapy, and medication management services offered within Opioid treatment programs may be reimbursed when conducted via telecommunication technology. The LMHP is responsible for acting within the telehealth scope of practice as decided by the respective licensing board. The provider must bill the procedure code (CPT codes) with modifier “95”, as well as the correct place of service, either POS 02 (other than home) or 10 (home). Reimbursement will be at the same rate as a face-to-face service. Exclusions: Methadone admission visits conducted by the admitting physician within OTPs are not allowed via telecommunication technology.

SOURCE: LA Dept. of Health and Hospitals, Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 113-114, 199-200 & 270 (As issued 5/13/24). (Accessed Jun. 2024).

Parent-Child Interaction Therapy

Fidelity is then directly assessed via the following requirement: Applicants must have their treatment sessions observed by a certified PCIT Trainer. Observations may be conducted in real time (e.g., live or online/telehealth) or through video recording.

Dialectical Behavioral Therapy

As an outpatient therapy service delivered by licensed practitioners, allowed modes of delivery include individual, family, group, on-site, off-site, and tele-video. Telehealth delivery is allowed if it includes synchronous, interactive, real-time electronic communication comprising both audio and visual elements.

A comprehensive DBT program is typically provided in an outpatient setting. Telehealth is an allowed modality, and use of telehealth for DBT skills training groups in particular may support continued and consistent client engagement, especially when travel or transportation is a barrier to client engagement.

Components of DBT may be delivered, with some adaptation, in a residential or inpatient setting; however, this would not be billed as a separate service, instead would be part of the active treatment plan reimbursed as part of the comprehensive inpatient or psychiatric residential treatment facility (PRTF) rate

Only direct staff face-to-face time with the individual or family may be billed. DBT is a face-to-face intervention with the individual present. Telehealth delivery is allowed if it includes synchronous, interactive, real-time electronic communication comprising both audio and visual elements. Services provided using telehealth must be identified on claims submission by appending the modifier “95” to the applicable procedure code and indicating the correct place of service, either POS 02 (other than home) or 10 (home). Both the correct POS and the 95 modifier must be present on the claim to receive reimbursement;

SOURCE: LA Dept. of Health and Hospitals, Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, 415, 461, 470 (As issued 5/13/24). (Accessed Jun. 2024).

Ambulance Providers – Managed Care Organizations

Physician directed treatment-in-place service is the facilitation of a telehealth visit by an ambulance provider.

MCO Manual: The MCO may not reimburse for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident.

Medical Transportation Manual: Reimbursement for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident is not permitted.

SOURCE: LA Medicaid Managed Care Organization (MCO) Manual, p. 88 (Updated 6/11/24), & LA Dept. of Health, Medical Transportation, Sec. 10.8, (As issued on 2/16/24), (Accessed Jun. 2024).

Early and Periodic Screening, Diagnostics and Treatment Health Services (EPSDT)

Louisiana Medicaid allows for the telemedicine/telehealth mode of delivery for many common healthcare services.

Permissible Telecommunications Systems:

All services eligible for telemedicine/telehealth may be delivered via an interactive audio/video telecommunications system;
A secure, HIPAA-compliant platform is preferred, if available. However, for the duration of the COVID-19 event, if a HIPAA-compliant system is not immediately available at the time it is needed, providers may use everyday communications technologies such as cellular phones with widely available audio/video communication platforms;
Providers should follow guidance from the Office for Civil Rights at the Department of Health and Human Services for software deemed appropriate for use during this event;
For the duration of the COVID-19 event, in cases where an interactive audio/video system is not immediately available at the time it is needed, an interactive audio-only system (e.g., telephone) without the requirement of video may be employed, unless noted otherwise;
For use of an audio-only system, the same standard of care must be met, and the need and rationale for employing an audio-only system must be documented in the clinical record; and
Please note, some telemedicine/telehealth services described below require delivery through an audio/video system due to the clinical nature of these services. Where applicable, this requirement is noted explicitly.

As always, providers must maintain the usual medical documentation to support reimbursement of the visit. In addition, providers must adhere to all telemedicine/telehealth-related requirements of their respective professional licensing boards.

Reimbursement for services delivered through telemedicine/telehealth is at the same level as reimbursement for in-person services.

Providers must indicate place of service 02 and must append modifier -95.

SOURCE: LA Dept. of Health, Provider Manual, Chapter Twenty of the Medicaid Svcs. Manual, Section 20.1, p. 19-20 (As issued 3/14/24). (Accessed Jun. 2024).

Consultations are to be face-to-face contact in one-on-one sessions. These are services for which a parent would otherwise seek medical attention at a physician or health care provider’s office. Telemedicine/telehealth is not a covered service, but is an applicable service delivery method. When otherwise covered by Louisiana Medicaid, telemedicine/telehealth is allowed for all CPT codes located in Appendix P of the CPT manual. This service is available to all Medicaid individuals eligible for EPSDT.

SOURCE: LA Admin Code, Title 50, Part XV, Subpart 5, Ch. 95, Sec. 9503, p. 393 (Accessed Jun. 2024).

The department shall include in its Medicaid policies and procedures all of the following information relating to telehealth:

An exhaustive listing of the covered healthcare services which may be furnished through telehealth.
Processes by which providers may submit claims for reimbursement for healthcare services furnished through telehealth.
The conditions under which a managed care organization may reimburse a provider or facility that is not physically located in this state for healthcare services furnished to an enrollee through telehealth.

SOURCE: LA Revised Statute, Ch. 46, Sec. 460.54, (Accessed Jun. 2024).

For services rendered in the natural environment (home and community). “Community”: environment where children of same age with no disabilities or special needs participate such as childcare centers, agencies, libraries, and other community settings. Services can be provided via “teletherapy” specific POS/modifier combinations.

POS/modifier combination must be one of these two choices:

POS 12 (Home) and Procedure Modifier U8; or
POS 99 (Other Place of Service) and Procedure Modifier U8.
POS 02 (Teletherapy) and Procedure Modifiers 95 and U8.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, EPSDT Health and IDEA, Part C- Early Steps, Section 47.5.1, p. 21 (As issued on 2/27/23), (Accessed Jun. 2024).

Supports Waiver

Virtual delivery of onsite day habilitation should be utilized during times that does not allow the beneficiary to attend in person (i.e. medical issues/surgery, an emergency where a provider agency may be closed) or when the beneficiary chooses to not attend in person. Virtual delivery is not the typical delivery method. In order to participate in virtual delivery of the service, the beneficiary should be independent or have natural supports, as this service cannot be billed at the same time as another service. The beneficiary should also have the technology necessary to participate in the virtual service (i.e., internet connection, laptop, smartphone, and/or tablet).

See manual for virtual delivery guidelines.

SOURCE: LA Dept. of Health, Support Services, Ch. 43.4, (As issued on 8/21/23), (Accessed Jun. 2024).

Applied Behavior Analysis

Louisiana Medicaid will reimburse the use of telehealth, when appropriate, for rendering certain ABA services for the care of patients or to support the caregivers of beneficiaries.

Telehealth requires prior authorization for services. Subsequent assessments and behavior treatment plans can be performed remotely via telehealth only if the same standard of care can be met.

Previously approved prior authorizations can be amended to increase units of care and/or to reflect re-assessment goals.

The codes listed below can be performed via telehealth; however, requirements for reimbursement are otherwise unchanged from Section 4.5 – Reimbursement of this manual chapter. See manual for relevant CPT codes.

SOURCE: LA Dept of Health, Applied Behavior Analysis, pg. 12, (As issued on 4/22/24), & Healthy Louisiana Informational Bulletin 24-13, May 6, 2024, (Accessed Jun. 2024).

RHCs/FQHCs

If a covered service is provided via an interactive audio and video telecommunications system (telemedicine), providers must refer to Chapter 5 of the Professional Services Provider Manual on www.lamedicaid.com for specific billing instructions.

SOURCE: LA Dept. of Health, FQHCs, Ch. 22, (as issued 6/30/22), & RHCs, Ch. 40, (as issued 6/30/22), pg. 33, (Accessed Jun. 2024).

ELIGIBLE PROVIDERS

Distant site means the site at which the physician or other licensed practitioner is located at the time the services are provided.

The distant site provider must be enrolled as a Louisiana Medicaid provider to receive reimbursement for covered services rendered to Louisiana Medicaid beneficiaries.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165 (As issued on 6/27/22) (Accessed Jun. 2024).

Distant site means the site at which the physician or other licensed practitioner is located at the time the telehealth services are provided.

SOURCE: Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 113, 172, & 199 (As issued 5/13/24). (Accessed Jun. 2024).

Rural health clinics (RHC) and federally qualified health clinics (FQHC): Reimbursement for these services will be at the all-inclusive prospective payment rate on file for the date of service (DOS).

SOURCE: LA Dept. of Health, Informational Bulletin 20-1. (May 20, 2022). (Accessed Jun. 2024).

FQHC manual refers to provider manual for billing instructions for telemedicine services.

SOURCE: LA Dept. of Health, Federally Qualified Health Centers Provider Manual, Chapter 22, Sec. 22.4, pg. 33, (As issued on Jun. 30, 2022) & Rural Health Clinic Manual, Chapter 40, Sec. 40.4, pg. 33 (As issued on Jun. 30, 2022). (Accessed Jun. 2024).

Distant Site: The distant site refers to where the provider is located. The preferred location of a distant site provider is in a healthcare facility. However, if there is disruption to a healthcare facility or a risk to the personal health and safety of a provider, there is no formal limitation as to where the distant site provider can be located, as long as the same standard of care can be met.

SOURCE: LA Dept. of Health, EPSDT Health and IDEA Related Services, Ch. 20, Sec. 20.1, (As issued on 3/14/24), (Accessed Jun. 2024).

Treatment-in-place ambulance services

Ambulance providers interested in offering physician directed treatment-in-place telehealth services must complete the following:

enroll as a CMS ET3 model participant;
enter into a partnership with a qualified, Louisiana Medicaid enrolled healthcare provider to furnish treatment-in-place telehealth services to Louisiana Medicaid beneficiaries; and
notify the Department of Health of its partnerships with each telehealth provider.
Reimbursement for initiation and facilitation of telehealth services shall be made according to the established physician directed treatment-in-place telehealth service fee schedule or billed charges, whichever is the lesser amount.

Initiation and facilitation of physician directed treatment-in-place telehealth services are performed by Louisiana Medicaid enrolled ambulance providers on site, with no transport, using audio and video telecommunications systems that permit real-time communication between a qualified, Medicaid enrolled, licensed medical practitioner and the beneficiary.

All services provided by ambulance providers during the initiation and facilitation of the physician directed treatment-in-place intervention are covered by the associated BLS-E, emergency base rate, or the ALS1-E, Level 1 emergency base rate.

Ambulance providers are not eligible to submit a claim for reimbursement or receive payment for other services (except for supplies) at the scene.

If a beneficiary must be transported to an emergency department (ED) due to poor internet connection, which resulted in a failed physician directed treatment-in-place encounter, or the beneficiary’s condition deteriorates, the ambulance provider may submit a claim for reimbursement and receive compensation for the transport to the ED, but not for initiation and facilitation of the telehealth service.

The entity seeking reimbursement for the corresponding physician directed treatment-in-place telehealth service must be an enrolled Louisiana Medicaid provider.

Reimbursement to the ambulance providers for initiation and facilitation of the physician directed treatmentin-place telehealth service requires a corresponding treatment-in-place telehealth service. The corresponding treatment-in-place telehealth service is demonstrated via a Louisiana Medicaid paid treatment-in-place telehealth service claim.

SOURCE: LA Admin Code, Title 50, Part IX, Subpart 1, Ch. 13, Sec. 1301-1305, p. 336 (Accessed Jun. 2024).

Valid rendering providers are licensed physicians, advanced practice registered nurses, and physician assistants.

SOURCE: MCO Manual (revised 6/11/24), pg. 89, & LA Dept. of Health and Hospitals, Medical Transportation, Sec. 10.8, (As issued on 2/16/24), (Accessed Jun. 2024).

School Based Health Centers provide convenient access to preventive and acute care services for students who might otherwise have limited or no access to health care. This care may be provided onsite or through telehealth.

SOURCE: LA Admin Code, Title 50, Park XV, Subpart 5, Ch. 91, pg. 388 (Accessed Jun. 2024).

ELIGIBLE SITES

Originating site means the location of the Medicaid beneficiary [enrollee, member] at the time the services are provided. There is no restriction on the originating site and it can include, but is not limited to, a healthcare facility, school, or the beneficiary’s [enrollee’s] home.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165. (As issued 6/27/22), & MCO Manual (revised 6/11/24), pg. 175, & Behavioral Health Services, Chapter Two of the Medicaid Svcs. Manual, Section 2.3, p. 113, 172, 199 (As issued 5/13/24). (Accessed Jun. 2024).

The Centers for Medicare and Medicaid Services (CMS) added a new place of service (POS) for telehealth services provided in the patient’s home effective for dates of service on and after January 1, 2022. Providers are required to use the appropriate POS, either 02 (other than home) or 10 (home) with modifier 95 for the billing of telemedicine/telehealth services based on the beneficiary’s location at the time of service.

SOURCE: LA Dept. of Health, Informational Bulletin 19-11. (May 18, 2022). (Accessed Jun. 2024).

Rural health clinics (RHC) and federally qualified health clinics (FQHC) are required to indicate the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of and append modifier 95 for the billing of telemedicine/telehealth services. Services delivered via an audio/video system and via an audio-only system are to be coded the same way.

SOURCE: LA Dept. of Health, Informational Bulletin 20-1. (May 20, 2022). (Accessed Jun. 2024).

Originating Site: The originating site refers to where the patient is located. There is currently no formal limitation on the originating site and this can include, but is not limited to, the patient’s home.

SOURCE: LA Dept. of Health, EPSDT Health and IDEA Related Services, Ch. 20, Sec. 20.1, (As issued on 3/14/24), (Accessed Jun. 2024).

GEOGRAPHIC LIMITS

A BHS provider that is not a licensed mental health professional or a provisionally licensed mental health professional acting within his/her scope of practice may not provide telehealth services outside of its geographic service area.

SOURCE: LA Admin Code 48:I Sec. 5605, (Accessed Jun. 2024).

FACILITY/TRANSMISSION FEE

Louisiana Medicaid only reimburses the distant site provider.

SOURCE: LA Dept. of Health, Professional Svcs. Provider Manual, Chapter Five of the Medicaid Svcs. Manual, Section 5.1, p. 165 (As issued on 6/27/22). (Accessed Jun. 2024).

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Maine

Last updated 05/20/2024

POLICY

If a Member is eligible for the underlying Covered …

POLICY

If a Member is eligible for the underlying Covered Service to be delivered, and if delivery of the Covered Service via Telehealth Services is medically appropriate, as determined by the Health Care Provider, the Member is eligible for Telehealth Services.

Except as set forth herein, reimbursement will not be provided for communications between Health Care Providers when the Member is not participating.

Except as set forth herein, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

Reimbursement

Services are to be billed in accordance with applicable Sections of the MBM. Providers must submit claims in accordance with Department billing instructions.

Telehealth Services are subject to all conditions and restrictions described in Chapter I, Section 1, of the MBM.

Telehealth Services are subject to co-payment requirements for the underlying Covered Service, if applicable, as established in Chapter I, Section 1, of the MBM. However, there shall be no separate co-payment for telehealth services.

Specific reimbursement rates for other telehealth services can be found in the appropriate Sections of the MBM or the MaineCare Provider fee schedules on the MaineCare Health PAS Portal.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed May 2024).

“Synchronous encounters” means a real-time interaction conducted with interactive audio or video connection between a patient and the patient’s provider or between health professionals regarding the patient.

SOURCE: ME Statute Sec. 22:855.3173-H, Sub. Sec. 1 (Accessed May 2024).

ELIGIBLE SERVICES/SPECIALTIES

Any medically necessary MaineCare Covered Service may be delivered via Telehealth Services, provided the following requirements are met:

The Member is otherwise eligible for the Covered Service, as described in the appropriate Section of the MBM; and
The Covered Service delivered by Telehealth Services is of comparable quality to what it would be were it delivered in person.

Prior authorization is required for Telehealth Services only if prior authorization is required for the underlying Covered Service. In these cases, the prior authorization is the usual prior authorization for the underlying Covered Service, rather than a prior authorization for the mode of delivery. Unless otherwise required by law, a face-to-face encounter is not required prior to delivering Telehealth Services.

Non-Covered Services and Limitations

Except as set forth herein, services not otherwise covered by MaineCare are not covered when delivered via Telehealth Services.

Services covered under other MaineCare Sections but specifically excluded from Telehealth coverage include, but are not limited to the following:

Services that require direct physical contact with a Member by a Health Care Provider and that cannot be delegated to another Health Care Provider at the site where the Member is located are not covered;
Any service medically inappropriate for delivery through Telehealth Services – e.g. services that include providing medical procedures or administration of medications that must be conducted in person.

Except as set forth herein, reimbursement will not be provided for communications between Health Care Providers when the Member is not participating.

Except as set forth herein, reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

The Originating Site Fee may be paid only to a Health Care Provider.

Virtual Check-In

Virtual Check-in is a brief communication where an established patient checks in with a Health Care Provider using a telephone or other telecommunications device for 5-10 minutes to determine the status of a chronic clinical condition(s) and to determine whether an office visit is needed. Modalities permitted for Virtual Check-Ins include Telephonic Services or Interactive Services to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.

Communications exclusively by email, text, or voicemail are not reimbursable.

The Health Care Provider must document a Virtual Check-In in the Member’s record, including the length of the Virtual Check-In, an overview and outcome of the conversation, and the modality of the interaction.

If the Virtual Check-In takes place within seven (7) days after an in-person visit or triggers an in-person office visit within 24 hours (or the soonest available appointment), the Virtual Check-In is not billable under this Section.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., (Nov. 6, 2023). (Accessed May 2024).

Rules adopted by the department:

May not include any requirement that a patient have a certain number of emergency room visits or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s eligibility for telemonitoring services;
Except as provided in paragraph E, must include qualifying criteria for a patient’s eligibility for telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room;
Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth;
Must include requirements for providers providing telehealth and telemonitoring services; and
Must allow at least some portion of case management services covered by the MaineCare program to be delivered through telehealth, without requiring qualifying criteria regarding a patient’s risk of hospitalization or admission to an emergency room.

SOURCE: ME Revised Statute Sec. 3173,-H, (Accessed May 2024)

A multitude of services are listed as being allowed either face-to-face or through telehealth in the behavioral health services manual.

SOURCE: MaineCare Benefits Manual, Behavioral Health Services, 10-44 Ch. II, Sec. 65, (Nov. 9, 2022). (Accessed May 2024).

Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations

Telemedicine may be utilized as clinically appropriate, according to the standards described in Chapter I, Section 4 of the MaineCare Benefits Manual.

SOURCE: MaineCare Benefits Manual, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations, 28.08, Ch. 101, Ch. II, Sec. 28, p. 12, (9/23/19), (Accessed May 2024).

Durable Medical Equipment

A face-to-face encounter is a mandatory encounter (including encounters through telehealth (as described in Chapter I, Section 4) and other than encounters incidental to services involved) between the member and a Qualified Provider that takes place within the six (6) months prior to the date of a written order for DME. The written order may be, but does not have to be, prescribed by the provider who performed the face-to-face encounter.

SOURCE: MaineCare Benefits Manual, Durable Medical Equipment, 60.06, Ch. 101, Ch. II, Sec. 60, p. 4, (10/31/23), (Accessed May 2024).

Children’s Residential Care Facilities (CRCFs)

The nurse may provide in-person, telehealth, and/or telephonic support outside of normal business hours as needed. The nurse must be either a psychiatric mental health nurse practitioner (APRN-PMH-NP), or a registered nurse (RN) with experience in the treatment of children with serious behavioral health conditions or requisite training to treat children with serious behavioral health conditions.

SOURCE: MaineCare Benefits Manual, Private Non-Medical Institution, 97.07, Ch. 101, Ch. II, Sec. 97, (11/1/21), (Accessed May 2024).

Teledentistry

Providers may deliver diagnostic services via telehealth in accordance with Chapter I, Section 4, of the MaineCare Benefits Manual (MBM) and current Board rules and guidance. When delivering services via telehealth, providers shall bill for the underlying service and include, for tracking purposes only, the appropriate teledentistry CDT code that indicates a synchronous real-time encounter or an asynchronous encounter in which information is stored and forwarded to the dentist for subsequent review.

SOURCE: ME Benefits Manual, Dental Services and Reimbursement Methodology, 10-144, Ch. II, Sec. 25, pg. 1, (Sept. 28, 2022), (Accessed May 2024).

Primary Care Plus (PCP)

In PCP Tier II Services, providers must offer telehealth as an alternative to traditional office visits in accordance with MBM, Ch. I, Sec. 4, Telehealth Services, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of Members.

SOURCE: MaineCare Benefits Manual, Primary Care Plus, 10-144, Ch. VI, Sec. 3.03, pg. 6, June 21, 2022, (Accessed May 2024).

Home Health Services

Face to Face Encounter means an encounter between the member and the certifying physician, or a nurse practitioner or clinical nurse specialist who is working in collaboration with the physician, or a certified nurse midwife as authorized by State law or physician assistant under the supervision of the physician. The encounter may be through telehealth, consistent with Section 1834(m) of the Social Security Act and 42 CFR 424.22. The face-to-face encounter must be related to the primary reason the patient requires Home Health Services.

SOURCE: Main Care Benefits Home Health Services, 10-144, Chapter II, Section 40 (Aug. 11, 2019), p. 1. (Accessed May 2024).

Community Care Teams

A comprehensive biopsychosocial assessment, conducted face-to-face or via telehealth. See manual for necessary components.

SOURCE: Maine Care Benefits Manual Home Health Services – Community Care Teams, 10-144, Chapter II, Section 91 (June 21, 2022), p. 15, (Accessed May 2024).

Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder

AT-Assessment: Evaluation of the assistive technology needs of a member, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the member in the customary environment of the member.

Evaluation of the assistive technology needs of a Member may be delivered via telehealth when the provider ensures that the assessment via telehealth meets the requirements of the scope of the service.

SOURCE: Maine Care Benefits Manual Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder, 10-144, Chapter II, Section 29 (Jan. 24, 2024), p. 15, Adopted Rule: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter II, Section 29, Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (Jan. 12, 2024). (Accessed May 2024).

Diabetes Prevention Program

Providers shall bill 0403T for each in-person session and bill 0403T with the GT modifier for sessions delivered through telehealth, e.g. online and distance learning sessions, as defined in the DPRP Standards.

SOURCE: Maine Care Benefits Manual National Diabetes Prevention Program Services, 10-144, Chapter II, Section 71 (Nov. 8, 2023), p. 5, Adopted Rule: 10-144 C.M.R. Chapter 101, Chapter II, Section 71, National Diabetes Prevention Program Services (Nov. 8, 2023). (Accessed May 2024).

MaineMOM Services and Reimbursement

The MaineMOM provider shall offer telehealth as an alternative to traditional office visits in accordance with the MBM, Chapter I, Section 4, and/or for non-office visit supports and outreach to increase access to the care team and clinicians in a way that best meets the needs of members.

SOURCE: MaineCare Benefits Manual, MaineMOM Services and Reimbursement, 10-44 Ch. II, Sec. 89, p. 22 (Dec. 6, 2023). (Accessed May 2024).

Newly Adopted Rule:

MaineCare will reimburse providers for one health assessment visit per member for each age shown on the Bright Futures Periodicity Schedule. The Department covers one additional health assessment visit per member within a year following an initial assessment via telehealth for each age shown on the Bright Futures Periodicity Schedule.

SOURCE: MaineCare Benefits Manual, Early and Periodic Screening, Diagnosis and Treatment Services, 10-44 Ch. II, Sec. 94, p. 10 (Apr. 22, 2024) Adopted Rule: 10-144 C.M.R., Chapter 101, MaineCare Benefits Manual, Chapter II Section 94, Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) (Apr. 22, 2024). (Accessed May 2024).

Note: MaineCare issued a notice indicating they plan to submit a waiver renewal for the MaineCare Benefits Manual, Section 18, Home and Community Based Services for Members with Brain Injury which will include updates to assistive technology services by allowing qualified providers to conduct Assistive Technology Assessments via telehealth when the provider ensures that the assessment via telehealth meets the requirements of the scope of the service. The manual does not yet indicate this change.

SOURCE: MaineCare Benefits Manual, Notice of Agency Waiver Renewal: Section 18, Home and Community Based Services for Members with Brain Injury, Mar. 22, 2024, (Accessed May 2024).

ELIGIBLE PROVIDERS

A health care provider is an individual or entity licensed or certified to provide medical, behavioral health, and related services to MaineCare Members. Health Care Providers must be enrolled as MaineCare Providers to receive reimbursement for services.

In order to be eligible for reimbursement for Telehealth Services, a Health Care Provider must

Act within the scope of their license;
Be enrolled as a MaineCare provider;
Be otherwise eligible to deliver the underlying Covered Service according to the requirements of the applicable Section of the MBM; and
Be appropriately licensed, accredited, certified, and/or registered in the State where the Member is located during the provision of the Telehealth Service.

Reimbursement – Receiving (Provider) Site

Except as described below, only the Health Care Provider at the Receiving (Provider) Site may receive payment for Telehealth Services.
When billing for Telehealth Services, Health Care Providers at the Receiving (Provider) Site must bill for the underlying Covered Service using the same claims they would if it were delivered face-to-face and must add the GT modifier for Interactive Telehealth Services and the 93 modifier for Telephonic Services.
When billing for Telephone Evaluation and Management Services, Health Care Providers at the Receiving (Provider) Site must use the appropriate E&M code. The GT and 93 modifier should not be used.
No separate transmission fees will be paid for Telehealth Services. The only services that may be billed by the Health Care Provider at the Receiving (Provider) Site are the fees for the underlying Covered Service delivered with the GT or 93 modifier.

The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. A Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a Treating Provider who is under a contractual arrangement with the Originating (Member) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03., (Nov. 6, 2023). (Accessed May 2024).

Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 12. (Nov. 6, 2023). (Accessed May 2024).

Interprofessional Codes for Medication Management Providers

Medication management providers and other treating providers of Section 65 of the MaineCare Benefits Manual (MBM) may deliver and bill MaineCare for interprofessional consultations in alignment with MBM Chapter 1, Section 4.04-2(B). As described in CMS state health official letter #23-001, interprofessional consultations are assessments and management services in which a patient’s treating provider requests the opinion and/or treatment advice of a consultant with specific specialty expertise to assist the treating provider in the diagnosis and/or management of the patient’s condition without the need for the patient’s face-to-face contact with the consultant.

The consulting provider and the provider requesting the consultation must be able to independently bill for evaluation and management services. Examples of these provider types include physicians, nurse practitioners, clinical nurse specialists, physician assistants, and licensed clinical social workers. A registered nurse, for example, is not an eligible provider type.

The following examples illustrate when medication management providers may deliver and bill for interprofessional consultations:

A medication management provider provides consultation to a primary care provider (PCP) on cross-tapering a patient from one antidepressant to another due to concerning side-effects.
A medication management provider provides consultation to a PCP regarding antipsychotic medications because the PCP has a symptomatic patient who has been off of medications, and the PCP has never prescribed antipsychotic medication before.
The PCP has been treating a behavioral health patient who was previously stabilized and who is now reporting increased symptoms with active substance use. The PCP is not sure of what to do about medications in the context of active substance use and consults a medication management provider.

Providers must bill for interprofessional consultations using common procedural terminology (CPT) codes 99446-99449, 99451, and 99452. However, CPT code 99452 is different. Interprofessional consultation code 99452 applies when the patient’s PCP or other qualified health professional interacts with a consultant via telephone, the Internet, or an electronic health record to provide the consultant with the patient’s clinical data so that the consultant can form an opinion regarding further management of the patient’s condition. For example, a PCP would bill CPT code 99452 if they send a patient to a medication management provider and the PCP provided background information.

SOURCE: State of Maine Department of Health and Human Services, Bulletin: Interprofessional Codes for Medication Management Providers, Nov. 13, 2023, (Accessed May 2024).

Electronic Visit Verification (EVV) Place of Service Providers

Telehealth Personal Care Services (PCS) claims are excluded from Electronic Visit Verification (EVV) record requirements. When billing telehealth claims on the CMS 1500 Claim Form, you must use the POS code 02 or 10 and include the GT modifier, as this indicates you are providing services via telehealth and not in-person.

See the table below for affected codes. UB04 claim lines submitted with telemedicine revenue code 078x are exempt from EVV editing.

SOURCE: ME Department of Health and Human Services, Office of MaineCare Services, Electronic Visit Verification (EVV) Place of Service Reminders, Sept. 26. 2022. (Accessed May 2024).

ELIGIBLE SITES

Originating (Member) Site: The site at which the Member is located at the time of Telehealth Service delivery. The site must be physically located in the United States.

When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

Reimbursement – Originating (Member Site)

If the Health Care Provider at the Originating (Member) Site supports the Member’s access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.
The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.
No separate transmission fees will be paid for Telehealth Services.
The Health Care Provider at the Originating (Member) Site may bill for any clinical services provided on-site on the same day that a Telehealth Service claim is made, except as specifically excluded elsewhere in this Section.
Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.
In the event an interpreter is required, the Health Care Provider at either the Originating (Member) Site or the Receiving (Provider) site must provide and may bill for interpreter services in accordance with the provisions of Chapter I, Section 1, of the MBM. Members may not bill or be reimbursed by the Department for interpreter services utilized during a telehealth encounter.
If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site. The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site. The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023). Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023). (Accessed May 2024).

Electronic Visit Verification (EVV) Place of Service Reminders

Personal Care Services (PCS) claims are included or excluded from EVV record requirements based on the POS code and EVV service codes that are submitted on the CMS 1500 claim form.

Claims for services delivered in the following locations are not subject to EVV and do not require a verified EVV visit record:

POS 02: Telehealth provided other than in a patient’s home
- Use this POS for Home Support-Remote Support: Monitor Only and Interactive services (including MaineCare policy Sections 18, 19, 20, 21, and 29).
- Please refer to our additional telehealth billing guidance for PCS.
POS 10: Telehealth provided in patient’s home

SOURCE: ME Department of Health and Human Services, Office of MaineCare Services, Electronic Visit Verification (EVV) Place of Service Reminders, Sept. 26. 2022. (Accessed May 2024).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Originating Facility Fee: Fee paid to the Health Care Provider at the Originating (Member) Site for the service of coordinating Telehealth Services.

If the Health Care Provider at the Originating (Member) Site supports the Member’s access to Telehealth Services the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of supporting access to the Telehealth Service. Supporting access to telehealth services means providing a room and/or telecommunications equipment and/or helping a Member use audio or video conferencing software or equipment to enable the Member to utilize telehealth.

The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.

No separate transmission fees will be paid for Telehealth Services.

When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

If the technical component of an X-ray, ultrasound, or electrocardiogram is performed at the Originating (Member) Site during a Telehealth Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site.

The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

The Department will not separately reimburse Health Care Providers for any charge related to the purchase, installation, or maintenance of telehealth equipment or technology, nor any transmission fees. Health Care Providers shall not bill Members for such costs or fees.

The rate for Telehealth Originating Facility Fee, per visit, code Q3014, is listed on the MaineCare Provider fee schedule, which is posted on the Department’s website in accordance with 22 MRSA Section 3173-J(7) at https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx.

READ LESS

Maryland

Last updated 05/24/2024

POLICY

Reimbursement for telehealth is required for services appropriately delivered …

POLICY

Reimbursement for telehealth is required for services appropriately delivered through telehealth regardless of the location of the patient and may not exclude from coverage a health care service or behavioral health service solely because it is through telehealth.

SOURCE: MD Health General Code 15-141.2 (Accessed May 2024).

Maryland Medicaid reimburses providers for services delivered via synchronous telehealth. Synchronous telehealth is defined as real-time interactive communication between the originating and distant sites via a secure, two-way audiovisual telecommunication system, and for some services audio-only, depending on the program.

The “distant site,” is the location of the provider who will perform the services. The “distant site provider” is the rendering practitioner that is not physically present at the originating site.

The “originating site” is where the participant/patient is located.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1. Updated Aug. 2023. (Accessed May 2024).

Mental Health

The Department shall grant approval to a telemental health provider to be eligible to receive State or federal funds for providing interactive telemental health services if the provider meets requirements of this chapter and for outpatient mental health centers; or if the telemental heath provider is an individual psychiatrist.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.03. (Accessed May 2024).

Managed Care

MCOs shall provide coverage for medically necessary telemedicine services.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.67.06.31. (Accessed May 2024).

ELIGIBLE SERVICES/SPECIALTIES

Services provided through telehealth are subject to the same program restrictions, preauthorizations, limitations and coverage that exist for the service when provided in-person.

A provider may receive reimbursement for services delivered via telehealth if the participant:

Consents to service rendered via telehealth (unless there is an emergency that prevents obtaining consent, which shall be documented in the participant’s medical record); and,
Is authorized to receive services, except for services provided in a hospital emergency department

Providers must include the “GT” modifier with the billed procedure code to identify services rendered via audio-video telehealth.

Providers should use the place of service code that would be appropriate as if it were a non-telehealth claim. The billing provider should use the location of the rendering practitioner. If a distant site provider is rendering services at an off-site office, use the place of service office (11). Do not use place of service codes 02 (Telehealth-Other than home) and 10 (Telehealth-Home) for Medicaid-only FFS claims. Medicare Crossover Claims: For Medicare crossover claims, billing providers should use the same Place of Service Code as on the Medicare claim submission: 02 (Telehealth-Other than home) and 10 (Telehealth-Home) are permitted for use on crossover claims only.

For services delivered via audio-visual telehealth, a provider may not bill:

When technical difficulties prevent the delivery of all or part of the telehealth session;
Services that require in-person evaluation or cannot be reasonably delivered via telehealth;
Telecommunication between providers without the participant present

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1-3. Updated Aug. 2023. (Accessed May 2024).

Mental Health Eligible Services:

Diagnostic interview;
Individual therapy
Family therapy
Group therapy, up to 8 individuals
Outpatient evaluation and management
Outpatient office consultation
Initial inpatient consultation
Emergency department services

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.09. (Accessed May 2024).

Services required to be provided shall include counseling and treatment for substance use disorders and mental health conditions. The Program may not exclude from coverage a behavioral health care service provided to a Program recipient in person solely because the service may also be provided through telehealth.

The Program may undertake utilization review, including preauthorization, to determine the appropriateness of any health care service whether the service is delivered through an in–person consultation or through telehealth if the appropriateness of the health care service is determined in the same manner.

For the purpose of reimbursement and any fidelity standards established by the Department, a health care service provided through telehealth is equivalent to the same health care service when provided through an in–person consultation.

SOURCE: MD General Health Code 15-141.2(c-e, h). (Accessed May 2024).

Maryland Public Behavioral Health System – Deaf or Hard of Hearing

Maryland Medicaid will reimburse services delivered via telehealth to a patient that is deaf or hard of hearing by any enrolled provider that is fluent in ASL. Unlike telehealth for patients who are not deaf or hard of hearing, the patient may be located in their home. The originating site must meet the technological requirements listed in COMAR 10.09.49. If the ASL fluent provider is enrolled in Maryland Medicaid, actively licensed, and permitted within scope of practice to use telehealth, the provider may act as a distant site provider. The provider may bill for services rendered via telehealth to the patient that is deaf or hard of hearing, using the GT modifier. As with all specialty behavioral health services, the distant site provider is required to have authorizations for all services delivered via telehealth. More information, including the “Telehealth Program Manual,” can be found on the Maryland Medicaid Telehealth Program webpage.

SOURCE: Maryland PBHS Provider Manual (Sept. 2022), p. 35. (Accessed May 2024).

Doula Services

Prenatal and postpartum services may be delivered in the home, at the provider’s office or doctor’s office and other community-based settings. Doula services for prenatal and postpartum visits may be delivered in-person or as a telehealth service. The labor and delivery service must be provided in-person and can only be delivered at a hospital or freestanding birthing center.

The Maryland Medical Assistance Program will not cover Doula services rendered during labor and delivery as a telehealth visit.

SOURCE: MD Medicaid Doula Services Program Manual, p. 3, 5. Updated Jun. 30, 2023. (Accessed May 2024).

Effective January 1, 2022, the Program covers doula services as defined in Regulation .01 of this chapter when the services:

Are medically necessary;
Are rendered during a birthing parent’s prenatal period, labor and delivery, and postpartum period; and
If rendered via telehealth, comply with the requirements established in COMAR 10.09.49 and any other subregulatory guidance.

B. The Program shall cover up to:

Eight prenatal or postpartum visits; and
One labor and delivery service.

SOURCE: Code of Maryland Admin Regs. 10.09.39.04 (Accessed May 2024).

Individualized Education Program (IEP) and Individualized Family Service Plan (IFSP) Services

MDH Will reimburse IEP and IFSP providers for certain procedure codes via telehealth. Providers must identify telehealth services on the child’s IEP/IFSP and bill using the appropriate modifier (GT or UB). Service coordination procedures (T1023, T1023-TG, T2022, W9322, W9323, and W9324) and individual psychotherapy services (90791, 90832 and 90834) may continue with an audio-only component. In addition to IEP/IFSP services, MDH will continue to reimburse Autism Waiver service coordination when provided via telehealth. See Provider Transmittal for approved Maryland Medicaid Fee-for-Service approved IEP/IFSP Telehealth Services.

SOURCE: MD Medical Assistance Program. Early Intervention and School Health Service Providers Transmittal No. 3. Sept. 23, 2021. (Accessed May 2024).

GT Modifier required for telehealth delivered services.

SOURCE: MD Dept of Health, Medicaid Policy & Procedure Manual For Services Delivered through the IEP/IFSP (January 1, 2024). p. 25. (Accessed May 2024).

Therapy Services (Physical Therapists, Occupational Therapists, Speech Therapists, Therapy Groups, EPSDT Providers, Managed Care Organizations)

MDH will reimburse providers for certain procedure codes when provided via audio-visual telehealth. Services must be identified and billed using the GT modifier to indicate a telehealth delivery model. MDH will not reimburse for services provided via an audio-only delivery model or for codes not included on the Provider Transmittal regarding approved therapy telehealth services when provided via any method of telehealth.

SOURCE: MD Medical Assistance Program. Guidance on the Continuation of Telehealth for Therapy Services. PT 09-22. Oct. 7, 2021. MD Dept of Health, Audiology, Physical Therapy, and Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Manual (Jan. 2024). (Accessed May 2024).

Applied Behavior Analysis (ABA) Services

Maryland Medicaid reimburses for certain procedure codes via audio-visual telehealth for ABA providers. ABA providers may continue to render up to 100% of supervision services (97155) via telehealth. When billing for services that are rendered via two-way HIPAA compliant audio-visual telehealth, providers must bill using the GT modifier and Place of Service 11 to indicate a telehealth delivery model.

SOURCE: MD Medical Assistance Program. Guidance on the Continuation of Telehealth for ABA Services. PT 11-22. Oct. 26 2021. (Accessed May 2024).

The following services may be rendered via a two-way audio-visual telehealth delivery model:

Direct supervision of a BCaBA, RBT, or BT;
Parent training; and
Group parent training.

ABA services must be delivered in a home or community setting, including a clinic, when medically necessary. The ABA provider may not bill the Program for services rendered by mail or telephone or telehealth services that don’t meet the requirements in COMAR 10.09.49.

SOURCE: MD Department of Health, Maryland Medical Assistance Program Applied Behavior Analysis (ABA) Provider Manual (Jul. 2023), p. 8-9. (Accessed May 2024).

Dental Services

Coverage for teledentistry as described in previous guidance will continue to be permitted after the end of the PHE. See list of procedure codes in PT 56-23 PHE Unwinding for teledentistry. Services delivered via telehealth using two way audio- visual technology assisted communication should be billed using the Place of Service “02” to indicate use of telecommunication technology. For these services, audio-only or telephonic services are not reimbursable. This code does not require prior authorization from Maryland Medicaid.

SBHC Services

When billing for services rendered via audio-video or audio-only modalities, SBHC sponsoring agencies must adhere to the following:

Federal Rules (Clinic Services): SBHCs must adhere to federal Medicaid regulations governing clinics (42 CFR § 440.90 – Clinic Services). Medicaid may not reimburse SBHCs or other clinics if neither the practitioner nor patient is physically located within the clinic. This requirement applies to all freestanding clinics participating in the Maryland Medicaid program, regardless of whether they are community-based clinics or SBHCs.
1. During the PHE, CMS granted MDH an 1135 waiver permitting services provided via telehealth from clinic practitioners’ homes (or another location) to be considered to be provided at the clinic for purposes of 42 C.F.R. § 440.90(a). Under this authority, SBHCs were permitted to receive Medicaid reimbursement for services rendered if both the practitioner and the patient are in their homes for the duration of the federal government’s declared public health emergency. The waiver has a retroactive effective date of March 1, 2020, and will terminate when the federal public health emergency ends on May 11, 2023
Modifiers: When billing Medicaid or a HealthChoice MCO for an audio-video telehealth visit or an audio-only visit, sponsoring agencies should bill using the usual procedure code with the appropriate modifier.
1. To bill for services delivered via two-way audio-visual telehealth technology assisted communication, providers must bill for the appropriate service code and use the “-GT” modifier.
2. To bill for audio-only telephonic services, providers must bill for the appropriate service code and use the “-UB” modifier to identify the claim as a telephonically delivered service.
Place of Service (POS): SBHC sponsoring agencies should bill using the same POS code that would be appropriate for a non-telehealth claim.
1. If conducting a telehealth visit with a student enrolled with a SBHC (or family member who is also enrolled) who would normally be eligible to receive in-person care at the SBHC, sponsoring agencies should use POS code 03 (School). Sponsoring agencies should use POS code 03 for such visits regardless of the physical location of the student.
2. If a SBHC location adds or maintains telehealth services and wishes to use their telehealth service model to see patients they would not normally see (i.e., patients that are not associated with the student population), the sponsoring agency should not bill for the services as a SBHC. For such visits, sponsoring agencies should use POS code 11 (Office). Services to these recipients are not considered to be self-referred under COMAR 10.67.06.28. SBHCs should not use the 03 (School) POS when billing for services rendered to patients who would otherwise not be able to receive in-person care at the SBHC. MCOs also are not required to reimburse for such services if the sponsoring agency has not contracted with the MCO.
3. SBHCs may NOT bill using the 02 (Telehealth) code in the POS field.

Well-Child Visits

Coverage for well-child visits delivered via telehealth as described in previous guidance will continue to be permitted after the end of the PHE. This guidance does not apply to sick visits or chronic care appointments. See PT 56-23 PHE Unwinding for additional information and eligible codes.

SOURCE: MD Medicaid Provider Transmittal 56-23 PHE Unwinding, May 30, 2023. (Accessed May 2024).

Long Term Services and Supports

On December 22, 2021, via Provider Transmittal 27-22, the Maryland Department of Health (MDH), Medicaid Office of Long Term Services and Supports, authorized the continuation of reimbursement to providers for services determined to be clinically appropriate for delivery via telehealth. Effective July 1, 2023, the following services, which were previously authorized to be completed via telehealth, may no longer be provided in this manner and the MDH will not reimburse providers for these services delivered via telehealth:

Registered Nurse Supervisory Visits (Staff training and supervision)
Initial and significant change assessments (Private duty nursing)
Personal Assistance Services
Certain case management services

As previously discussed, effective July 1, 2023, the following services may continue to be provided via telehealth, MDH will reimburse providers for services delivered via telehealth below:

Model Waiver Case Management (when authorized by the Division of Nursing Services (DONS))
Psychological and psychiatric evaluations
Participant and family consultation
Certain case managment services and nurse monitoring

See PT 11-24 and 58-23 for additional details.

SOURCE: MD Medicaid Provider Transmittal 11-24 Discontinuation of Telehealth for Certain Services, Jul. 10, 2023 & MD Medicaid Provider Transmittal 58-23 Discontinuation of Telehealth for Certain Services, Jun. 7, 2023. (Accessed May 2024).

Behavioral Health Mobile Crisis Services

Mobile crisis team services are covered and shall include mobile crisis follow-up services by means of telephone, telehealth, or in-person contact with the individual served, family members, caregivers, or referred providers. A mobile crisis team program shall include at least one licensed mental health professional available at all times, either via telehealth or face-to-face.

SOURCE: COMAR 10.09.16 as proposed to be added by Final Regulation; COMAR 10.63.03.20 as proposed to be added by Final Regulation . (Accessed May 2024).

Collaborative Care Model (CoCM) Services: HealthChoice and Fee-for-Service

See chart on page 3 of guidance for CoCM Service reimbursement methodology for minimum payment for visits rendered in-person or via telehealth.

SOURCE: MD Medicaid Provider Transmittal No. 71-24, Superseding Guidance – Medicaid Coverage of Collaborative Care Model Services: HealthChoice and Fee-for-Service, Apr. 19, 2024, (Accessed May 2024).

ELIGIBLE PROVIDERS

“Health care provider” means:

A person who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care in the ordinary course of business or practice of a profession or in an approved education or training program;
A mental health and substance use disorder program licensed in accordance with § 7.5–401 of this article;
A person licensed under Title 7, Subtitle 9 of this article to provide services to an individual with developmental disability or a recipient of individual support services; or
A provider as defined under § 16–201.4 of this article to provide services to an individual receiving long–term care services.

SOURCE: MD General Health Code 15-141.2(a)(4). (Accessed May 2024).

The Program shall reimburse a health care provider for the diagnosis, consultation, and treatment of a Program recipient for a health care service covered by the Program that can be appropriately provided through telehealth. This subsection does not require the Program to reimburse a health care provider for a health care service delivered in person or through telehealth that is:

Not a covered health care service under the Program; or
Delivered by an out–of–network provider unless the health care service is a self–referred service authorized under the Program.

From July 1, 2021, to June 30, 2025, both inclusive, when appropriately provided through telehealth, the Program shall provide reimbursement on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
Any room and board fees.

The Department may specify in regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this section. If the Department specifies by regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this subsection, the regulations shall include all types of health care providers that appropriately provide telehealth services.

The Program or a managed care organization that participates in the Program may not impose as a condition of reimbursement of a covered health care service delivered through telehealth that the health care service be provided by a third–party vendor designated by the Program.

The Department may adopt regulations to carry out this section. The Department shall obtain any federal authority necessary to implement the requirements of this section, including applying to the Centers for Medicare and Medicaid Services for an amendment to any of the State’s § 1115 waivers or the State plan. This section may not be construed to supersede the authority of the Health Services Cost Review Commission to set the appropriate rates for hospitals, including setting the hospital facility fee for hospital–provided telehealth.

SOURCE: MD General Health Code 15-141.2(g-l). (Accessed May 2024).

All distant site providers enrolled in Maryland Medicaid may provide services via telehealth if telehealth is a permitted delivery model within the rendering provider’s scope of practice.

For participants physically located in Maryland, Maryland Health Professional Licensing Boards set licensure requirements. Providers should consult licensing boards (in both originating and distant site states, if applicable) prior to rendering services via telehealth to verify governing authority over licensure, as well as for information about the permitted use of telehealth as a service modality.

Providers delivering services via telehealth must use technology that supports the standard level of care required to deliver the service rendered.

Providers delivering services via telehealth submit claims in the same manner the provider uses for in-person services.

For audio-visual telehealth, services rendered must be performed via technology that is HIPAA compliant and meets Technical Requirements of COMAR 10.09.49.05.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 2-3. Updated Aug. 2023. (Accessed May 2024).

Only providers who are HIPAA compliant and meet technical requirements may bill for services rendered via telehealth.

SOURCE: MD Medical Assistance Program. Professional Services Provider Manual, p. 80. Updated Jan. 2024. (Accessed May 2024).

Distant Site Providers may render services via telehealth within the provider’s scope of practice.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.09.49.04(E). (Accessed May 2024).

Mental Health

Eligible Providers:

Outpatient mental health centers
Telemental health providers who are individual psychiatrists.

Telemental health providers may be private practice, part of a hospital, academic, health or mental health care system. Public Mental Health System (PMHS) approved community-based providers or individual practitioners may engage in agreements with TMH providers for services. Fee-for-service reimbursement shall be at an enhanced rate, as stipulated by the Department, provided all applicable provisions of this chapter are met and funds are available.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.03 & Sec. 10.21.30.04. (Accessed May 2024).

ELIGIBLE SITES

The Program shall provide health care services appropriately delivered through telehealth to Program recipients regardless of the location of the Program recipient at the time telehealth services are provided and allow a distant site provider to provide health care services to a Program recipient from any location at which the health care services may be appropriately delivered through telehealth.

SOURCE: MD General Health Code 15-141.2(b). (Accessed May 2024).

The originating site may be any secure location, approved by the participant and the provider, for the delivery of services. All distant site providers enrolled in Maryland Medicaid may provide services via telehealth if telehealth is a permitted delivery model within the rendering provider’s scope of practice.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 2. Updated Aug. 2023. (Accessed May 2024).

Maryland Public Behavioral Health System – Deaf or Hard of Hearing

SOURCE: Maryland PBHS Provider Manual (Sept. 2022), p. 35. (Accessed May 2024).

Mental Health

Eligible Originating Sites:

County government offices appropriate for private clinical evaluation services;

Critical Access Hospital;
Federally Qualified Health Center;
Hospital;
Outpatient mental health center;
Physician’s office;
Rural Health Clinic;
Elementary, middle, high, or technical school with a supported nursing, counseling or medical office; or
College or university student health or counseling office.

Distant Site Location Eligibility – An approved distant TMH location shall be within the State.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.05. (Accessed May 2024).

Providers should use the place of service code that would be appropriate as if it were a non-telehealth claim. The distant site should use the location of the doctor. If a distant site provider is rendering services at an off-site office, use place of service office (11). Place of Service Code 02 (Telehealth) is not recognized for Maryland Medicaid participants except for use on Medicare crossover claims to specify services rendered through a telecommunication system for dual eligible participants. Allowable place of service codes should remain unchanged for Medicaid-only claims.

The Program recognizes specific modifiers for certain services rendered via telehealth delivery models; providers may bill using -GT and -UB. Providers should submit claims in the same manner as for in-person services and include the “-GT” modifier to identify that services were rendered via two-way audio-visual telehealth. To bill for audio-only telephonic services, providers must bill for the appropriate service code and use the “-UB” modifier to identify the claim as a telephonically delivered service. Billing with these modifiers will not affect Medicaid reimbursement rates.

SOURCE: MD Medical Assistance Program. Professional Services Provider Manual, p. 25-26, 80. Updated Jan. 2024. (Accessed May 2024).

GEOGRAPHIC LIMITS

The Program may not distinguish between Program recipients in rural or urban locations in providing coverage under the Program for health care services delivered through telehealth.

SOURCE: MD General Health Code 15-141.2(f). (Accessed May 2024).

The telehealth care delivery model serves Medicaid participants regardless of geographic location.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 1. Updated Aug. 2023. (Accessed May 2024).

Mental Health

To be eligible a beneficiary must reside in one of the designated rural geographic areas or whose situation makes person-to-person psychiatric services unavailable.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.05(A)(3). (Accessed May 2024).

FACILITY/TRANSMISSION FEE

From July 1, 2021, to June 30, 2025, when appropriately provided through telehealth, the Program shall provide reimbursement in accordance on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
Any room and board fees.

The Department may adopt regulations to carry out this section.

SOURCE: MD Health General Code 15-141.2 (g)(3),(h). (Accessed May 2024).

A provider eligible to bill a professional fee for a health care service shall bill a professional fee for the health care service instead of a clinic facility fee.

SOURCE: Code of Maryland Admin. 10.09.49.07 (Accessed May 2024).

Hospital Billing Instructions

Facility charges related to the use of telemedicine services. This revenue code is payable for dates of service 10/1/13 forward. MDH cannot reimburse facility, room, or board charges for telehealth visits unless a professional fee cannot be billed separately.

SOURCE: Maryland Dept. of Health Medical Assistance, UB04 Hospital Billing Instru