Last updated 04/09/2022
Consent Requirements
Before providing a telehealth service to a member, the Provider shall inform the patient about the use of telehealth and document verbal, electronic or written consent from the patient or legally authorized representative, for the use of telehealth as an acceptable mode of delivering health care services. See Telehealth Supplement for requirements.
If a Provider, whether at the originating site or distant site, maintains a consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services including the information noted above, this shall meet DMAS’s required documentation of patient consent.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 7-8 (Mar. 2022) (Accessed Apr. 2022).
Last updated 04/08/2022
Definitions
“Telemedicine is a means of providing services through the use of two-way, real time interactive electronic communication between the member and the Provider located at a site distant from the member. This electronic communication must include, at a minimum, the use of audio and video equipment. Telemedicine does not include an audio-only telephone.”
“Telehealth means the use of telecommunications and information technology to provide access to medical and behavioral health assessment, diagnosis, intervention, consultation, supervision, and information across distance. Telehealth encompasses telemedicine as well as a broader umbrella of services that includes the use of such technologies as telephones, interactive and secure medical tablets, remote patient monitoring devices, and store-and-forward devices. Telehealth includes services delivered in the dental health setting (i.e., teledentistry), and telehealth policies for dentistry are covered in the dental manuals.”
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Mar. 2022) (Accessed Apr. 2022).
Last updated 04/09/2022
Email, Phone & Fax
Telehealth encompasses telemedicine as well as a broader umbrella of services that includes the use of such technologies as telephones, interactive and secure medical tablets, remote patient monitoring devices, and store-and-forward devices.
This electronic communication must include, at a minimum, the use of audio and video equipment. Telemedicine does not include an audio-only telephone.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 1 (Mar. 2022) (Accessed Apr. 2022).
Audio Only Services
Additions to the Telehealth Supplement include defining virtual check-in services, identifying covered codes, specifying reimbursement requirements, and outlining fee-for-service (FFS) billing details. See Update for list of codes.
As noted in the Telehealth Supplement (Attachment A), all FFS claims for audio only codes should be billed directly to DMAS, including those delivered in the context of mental health and substance use disorder services. Chapter V of the Physician/Practitioner Manual provides detailed billing instructions for submitting claims to DMAS.
SOURCE: VA Department of Medical Assistance Services, Coverage of Virtual Check-In and Audio Only Services/Updates to Telehealth Services Supplement, April 1, 2022. (Accessed Apr. 2022).
Last updated 04/08/2022
Live Video
POLICY
Services delivered via telehealth will be eligible for reimbursement when all of the following conditions are met:
- The Provider at the distant site deems that the service being provided is clinically appropriate to be delivered via telehealth;
- The service delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code, as defined by the American Medical Association (AMA);
- The service provided via telehealth meets all state and federal laws regarding confidentiality of health care information and a patient’s right to his or her medical information; and
- Services delivered via telehealth meet all applicable state laws, regulations and licensure requirements on the practice of telehealth; and
- DMAS deems the service eligible for delivery via telehealth.
In order to be reimbursed for services using telehealth that are provided to MCO-enrolled individuals, Providers must follow their respective contract with the MCO.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 2 & 3 (Mar. 2022) (Accessed Apr. 2022).
ELIGIBLE SERVICES/SPECIALTIES
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include:
- A provision for the payment of medical assistance for medically necessary health care services provided through telemedicine services regardless of the originating site or whether the patient is accompanied by a health care provider at the time such services are provided. No health care provider who provides health care services through telemedicine services shall be required to use proprietary technology or applications in order to be reimbursed for providing telemedicine services.
“Originating site” means any location where the patient is located, including any medical care facility or office of a health care provider, the home of the patient, the patient’s place of employment, or any public or private primary or secondary school or postsecondary institution of higher education at which the person to whom telemedicine services are provided is located.
SOURCE: VA Code Annotated Sec. 32.1-325, (Accessed Apr. 2022).
Telemedicine is available for selected services.
SOURCE: VA Dept. of Medical Assistance Svcs. General Information. All Manuals, pg. 9, Dec. 2021, (Accessed Apr. 2022).
Attachment A in the Telehealth Supplement lists covered services that may be reimbursed when provided via telehealth.
Certain types of services that would not be expected to be appropriately delivered via telemedicine include, but are not limited to, those 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
If, after initiating a telemedicine visit, the telemedicine modality is found to be medically and/or clinically inappropriate, or otherwise can no longer meet the requirements stipulated in the “Reimbursable Telehealth Services” section, the Provider shall provide or arrange, in a timely manner, an alternative to meet the needs of the individual (e.g., services delivered in-person; services delivered via telemedicine when conditions allow telemedicine to meet requirements stipulated in the “Reimbursable Telehealth Services” section). In this circumstance, the Provider shall be reimbursed only for services successfully delivered.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 3 (Mar. 2022) (Accessed Apr. 2022).
The following school-based services may be provided via telemedicine: PT, OT, speech and language, psychological and mental health, and medical evaluation services. DMAS does not require the presence of a paid staff person with the student at the time of the service, however, a paid staff person must be present and supervise the visit if the LEA submits a claim for the “originating site fee”.
SOURCE: VA Dept. of Medical Assistant Svcs. Medicaid Provider Manual, Local Education Agency Provider Manual, Covered Svcs. and Limitations, p. 12 (Oct. 2021). (Accessed Apr. 2022).
Durable Medical Equipment (DME) and Supplies
The face-to-face encounter to qualify for DME may occur through telehealth.
SOURCE: VA Dept. of Medical Assistant Svcs. Medicaid Provider Manual, Durable Medical Equipment and Supplies Manual, Covered Svcs. and Limitations, p. 8 (Jun. 2021). (Accessed Apr. 2022).
Opioid Treatment Services
Services can be provided face-to-face or by telemedicine according to DMAS policy regarding telemedicine.
SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Addiction and Recovery Treatment Services, Covered Svcs and Limitations p. 10 & 38. (Mar. 2022). (Accessed Apr. 2022).
MAT for Opioid Use Disorder
Prescribing controlled substances for the treatment of addiction delivered via telemedicine must include a qualified provider and a telepresenter located at the originating site, as well as a qualified prescribing provider located at the remote site. Psychotherapy and SUD counseling may also be provided via telemedicine by a qualified provider who is a credentialed addiction treatment professional as defined in this memorandum and DMAS ARTS Provider Manual. See manual for eligible MAT codes.
SOURCE: Medicaid Bulletin: Clarification of DMAS Requirements Related to the Use of Telemedicine in Providing MAT for OUD. Oct. 23, 2019, p. 3-4. (Accessed Apr. 2022).
Residential Treatment Service
DMAS reimburses for telemedicine services under limited circumstances. Telemedicine is the real-time or near real-time exchange of information for diagnosing and treating medical conditions. Telemedicine utilizes audio/video connections linking medical practitioners in one locality with medical practitioners in another locality. DMAS recognizes telemedicine as a means for delivering some covered Medicaid services.
SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Residential Treatment Services, Covered Services and Limitations, p. 5 (1/9/21), (Accessed Apr. 2022).
Vision Manual
CPT codes that are recognized by DMAS are listed. Codes include:
- Consultations
- Office visits
- Individual psychotherapy
- Psychiatric diagnostic interview examination
- Pharmacologic management
- Colostomy
- Obstetric ultrasound
- Echocardiography, fetal
- Cardiography interpretation and report only
- Echocardiography
SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Vision Manual, Billing Instructions, p. 23 (Jul. 2015), (Accessed Apr. 2022).
ELIGIBLE PROVIDERS
The term “Provider” refers to the billing provider – either a qualified, licensed practitioner of the healing arts or a facility – who is enrolled with DMAS.
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 HRSA and the Commonwealth. 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 site, the originating site fee is paid separately from the center or clinic all-inclusive rate.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 1 & 6, (Mar. 2022) (Accessed Apr. 2022).
Medication Assisted Treatment
The Member is located at an approved originating site with the Medicaid enrolled telepresenter. The originating site provider cannot bill an originating site fee unless the Member is assisted by a Medicaid enrolled telepresenter at the originating site.
SOURCE: Medicaid Bulletin: Clarification of DMAS Requirements Related to the Use of Telemedicine in Providing MAT for OUD. Oct. 23, 2019, p.4. (Accessed Apr. 2022).
Preferred OBOT services must be provided by a buprenorphine-waivered practitioner and a co-located Credentialed Addiction Treatment Professional and may be provided in a variety of practice settings including primary care clinics, outpatient health system clinics, psychiatry clinics, Federally-Qualified Health Centers (FQHCs), Community Service Boards (CSBs), local health department clinics, and physicians’/physician extenders’ offices. DMAS expects Preferred OBOT services to be primarily delivered in-person/on site and utilize telemedicine as an option to increase access to services as needed. DMAS does not support Preferred OBOTs services to be delivered solely or primarily through telemedicine. The practitioners must be credentialed by DMAS, the DMAS fee-for-service contractor or MCOs to perform Preferred OBOT services. Preferred OBOT providers do not require a separate DBHDS license.
Thus Preferred OBOT services may be provided via telemedicine based on the individualized needs of the member and must have supporting documentation of why the in-person interactions are not meeting the member’s specific needs. The primary means of services delivery shall be in-person for the Preferred OBOT model with the exception of telemedicine for specific member circumstances (such as transportation issues, childcare, employment, co-morbidities, distance, etc.) that impede their access to treatment. Providers delivering services using telemedicine shall bill according to the requirements in the DMAS Telehealth Services Supplemental Manual.
SOURCE: VA Dept. of Medical Assistance Svcs. Medicaid Provider Manual, Addiction and Recovery Treatment Services, Opioid Treatment Services/Medication Assisted Treatment, p. 16 & 21 & (Mar. 2022), (Accessed Apr. 2022).
ELIGIBLE SITES
The originating site is the location of the member at the time the service is rendered, or the site where the asynchronous store-and-forward service originates (i.e., where the data are collected). Examples of originating sites include: medical care facility; Provider’s outpatient office; the member’s residence or school; or other community location (e.g., place of employment).
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 HRSA and the Commonwealth. 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 site, the originating site fee is paid separately from the center or clinic all-inclusive rate.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 2 & 6 (Mar. 2022) (Accessed Apr. 2022).
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include:
- A provision for the payment of medical assistance for medically necessary health care services provided through telemedicine services regardless of the originating site or whether the patient is accompanied by a health care provider at the time such services are provided. No health care provider who provides health care services through telemedicine services shall be required to use proprietary technology or applications in order to be reimbursed for providing telemedicine services.
“Originating site” means any location where the patient is located, including any medical care facility or office of a health care provider, the home of the patient, the patient’s place of employment, or any public or private primary or secondary school or postsecondary institution of higher education at which the person to whom telemedicine services are provided is located.
SOURCE: VA Code Annotated Sec. 32.1-325, (Accessed Apr. 2022).
A Mobile Unit shall also be permitted to operate as an extension of an established Preferred OBOT’s primary location. This shall allow providers at a Preferred OBOT to also provide services in the community using the POS “015” for a Mobile Unit. Providers working in the Mobile OBOT setting shall provide services in-person as well as be permitted to utilize technology to provide telemedicine sessions with providers located at the Preferred OBOT’s primary location. Providers delivering services using telemedicine shall use the modifiers GT (interactive audio and video telecommunications system) or GQ (asynchronous telecommunications system) based on the guidance provided in the May 13, 2014 DMAS memo “Updates to Telemedicine Coverage” located on the DMAS Provider portal: http://www.virginiamedicaid.dmas.virginia.gov. Current Preferred OBOT Providers shall notify the MCOs and Magellan of Virginia prior to providing services in a Mobile Unit.
SOURCE: Department of Medical Assistance Services (DMAS). (April 30, 2021). (Accessed Apr. 2022).
GEOGRAPHIC LIMITS
No reference found.
FACILITY/TRANSMISSION FEE
In the event it is medically necessary for a Provider to be present at the originating site at the time a synchronous telehealth service is delivered, said Provider may bill an originating site fee (via procedure code Q3014) when the following conditions are met:
- The Medicaid member is located at a provider office or other location where services are delivered on an in-person basis (this does not include the member’s residence);
- The member and distant site Provider are not located in the same location;
- The distant site Provider providing the service also does not provide services on an in-person basis at the same location of the entity billing the Originating Site Fee; and
- The Provider (or the Provider’s designee), is affiliated with the provider office or other location where the Medicaid member is located and attends the encounter with the member. The Provider or designee may be present to assist with initiation of the visit but the presence of the Provider or designee in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.
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 HRSA and the Commonwealth. 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 site, the originating site fee is paid separately from the center or clinic all-inclusive rate.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 6 (Mar. 2022) (Accessed Apr. 2022).
The following school-based services may be provided via telemedicine: PT, OT, speech and language, psychological and mental health, and medical evaluation services. DMAS does not require the presence of a paid staff person with the student at the time of the service, however, a paid staff person must be present and supervise the visit if the LEA submits a claim for the “originating site fee”.
Service providers must include the modifier GT on claims for services delivered via telemedicine.
Place of Service (POS), the two-digit code placed on claims used to indicate the setting where the service occurred, must reflect the location in which a telehealth service would have normally been provided, had interactions occurred in person. The school setting code is 03. (Providers should not use POS 02 on telehealth claims, even though this POS is referred to as “telehealth” for other payers.
The services of a school employee supervising the student at the originating school site (the site where the student is located during the telehealth service), must be billed using procedure code, Q3014.
SOURCE: VA Dept. of Medical Assistant Svcs. Medicaid Provider Manual, Local Education Agency Provider Manual, Covered Svcs. and Limitations, p. 12 (Oct 2021) & Billing Instructions, pgs 25 & 26 (Oct. 2021), (Accessed Apr. 2021).
Medication Assisted Treatment
The originating site provider cannot bill an originating site fee unless the Member is assisted by a Medicaid enrolled telepresenter at the originating site.
SOURCE: Medicaid Bulletin: Clarification of DMAS Requirements Related to the Use of Telemedicine in Providing MAT for OUD. Oct. 23, 2019, p.4. (Accessed Apr. 2022).
Last updated 04/09/2022
Miscellaneous
See Telehealth Supplement for Documentation and Equipment/Technology Requirements.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), pgs. 8-9 (Mar. 2022) (Accessed Apr. 2022).
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include:
- A provision for payment of medical assistance services delivered to Medicaid-eligible students when such services qualify for reimbursement by the Virginia Medicaid program and may be provided by school divisions, regardless of whether the student receiving care has an individualized education program or whether the health care service is included in a student’s individualized education program. Such services shall include those covered under the state plan for medical assistance services or by the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), and shall include a provision for payment of medical assistance for health care services provided through telemedicine services. No health care provider who provides health care services through telemedicine shall be required to use proprietary technology or applications in order to be reimbursed for providing telemedicine services.
- A provision for the payment of medical assistance for medically necessary health care services provided through telemedicine services regardless of the originating site or whether the patient is accompanied by a health care provider at the time such services are provided. No health care provider who provides health care services through telemedicine services shall be required to use proprietary technology or applications in order to be reimbursed for providing telemedicine services.
- A provision for payment of medical assistance for remote patient monitoring services provided via telemedicine for:
- High-risk pregnant persons;
- Medically complex infants and children; Transplant patients;
- Patients who have undergone surgery, for up to three months following the date of such surgery; and
- Patients with a chronic health condition who have had two or more hospitalizations or emergency department visits related to such chronic health condition in the previous 12 months.
“Originating site” means any location where the patient is located, including any medical care facility or office of a health care provider, the home of the patient, the patient’s place of employment, or any public or private primary or secondary school or postsecondary institution of higher education at which the person to whom telemedicine services are provided is located.
“Remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload.
SOURCE: VA Code Annotated Sec. 32.1-325, (Accessed Apr. 2022).
Telemedicine also available for limited screening under the Governor’s Access Plan for the Seriously Mentally Ill (GAP).
SOURCE: VA Dept. of Medical Assistant Svcs., GAP Manual, p. 3 & 6 (Feb. 2019). (Accessed Apr. 2022).
Last updated 04/09/2022
Out of State Providers
Providers must maintain a practice at a physical location in the Commonwealth or be able to make appropriate referral of patients to a Provider located in the Commonwealth in order to ensure an in-person examination of the patient when required by the standard of care.
Providers must meet state licensure, registration or certification requirements per their regulatory board with the Virginia Department of Health Professions to provide services to Virginia residents via telemedicine. Providers shall contact DMAS Provider Enrollment (888-829-5373) or the Medicaid MCOs for more information.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 7 (Mar. 2022) (Accessed Apr. 2022).
Last updated 04/08/2022
Overview
Virginia Medicaid reimburses for live video, store-and-forward, remote patient monitoring and certain audio-only codes under certain circumstances. Plans participating in the Medicare-Medicaid Demonstration Waiver are permitted to use store-and-forward and remote patient monitoring in rural and urban locations and to provide reimbursement for services.
VA Medicaid recently moved the telehealth-specific content they had in their individual provider manuals into a ‘telehealth supplement’. Manuals that formerly included telehealth content now direct providers towards the telehealth supplement. Provider manuals that incorporate the supplement include:
- Addiction and Recovery Treatment Services (ARTS)
- Mental Health Services
- Early Intervention Services
- Physician/Practitioner
- Home Health
- Psychiatric Services
- Residential Treatment Services
See the Provider Manual home page to access all manuals.
Last updated 04/08/2022
Remote Patient Monitoring
POLICY
Face-to-face encounters may occur through telemedicine, which is defined as the two-way, real time interactive electronic communication between the member and the Provider located at a site distant from the member. This electronic communication must include, at a minimum, the use of audio and video equipment. Telemedicine shall not include by telephone or email.
SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual, Home Health Manual, Covered Services and Limitations. p. 5 (July 2021). (Accessed Apr. 2022).
VA Medicaid reimburses for Continuous Glucose Monitoring.
SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Clarification of Existing Medicaid Coverage of Continuous Glucose Monitoring for Members in Medicaid/FAMIS/FAMIS MOMS Fee-for-Service Programs. (Oct. 2016) (Accessed Apr. 2022).
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include a provision for payment of medical assistance for remote patient monitoring services provided via telemedicine for specific conditions (see section below).
“Remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload.
SOURCE: VA Code Annotated Sec. 32.1-325 (Accessed Apr. 2022).
Remote Patient Monitoring (RPM) involves the collection and transmission of personal health information from a beneficiary in one location to a provider in a different location for the purposes of monitoring and management. This includes monitoring of both patient physiologic and therapeutic data.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Physician/Practitioner) pgs 2 (Mar. 2022) (Accessed Apr. 2022).
DMAS and all managed care organizations (MCOs) will cover remote patient monitoring (RPM) services for full benefit Medicaid and FAMIS populations in accordance with the 2021 Special Session I Budget, Item 313.VVVVV. DMAS also has clarified guidance on select Behavioral Health codes eligible for telemedicine delivery included in the Telehealth Supplement.
See bulletin for additional information
SOURCE: VA Department of Medical Assistant Services. Bulletin Coverage of Remote Patient Monitoring/Update to Telehealth Services Supplement, (Mar. 2022). (Accessed Apr. 2022).
CONDITIONS
The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services. Such plan shall include:
- A provision for payment of medical assistance for remote patient monitoring services provided via telemedicine for:
- High-risk pregnant persons;
- Medically complex infants and children; Transplant patients;
- Patients who have undergone surgery, for up to three months following the date of such surgery; and
- Patients with a chronic health condition who have had two or more hospitalizations or emergency department visits related to such chronic health condition in the previous 12 months.
“Remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload.
SOURCE: VA Code Annotated Sec. 32.1-325 (Accessed Apr. 2022).
Coverage Continuous Glucose Monitoring is limited to members with:
- Type 1 diabetes
- Type 2 diabetes (when over 16 years old)
- Pregnant women who are injecting insulin with either Type 1 or 2.
Service authorization is required. Additional requirements apply.
SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Clarification of Existing Medicaid Coverage of Continuous Glucose Monitoring for Members in Medicaid/FAMIS/FAMIS MOMS Fee-for-Service Programs. (Nov. 2016) (Accessed Apr. 2022).
Effective for services with dates of service on and after May 1, 2022, RPM will be covered by FFS and MCOs for the following populations:
- Medically complex patients under 21 years of age
- Transplant patients
- Post-surgical patients
- Patients with a chronic health condition who have had two or more hospitalizations or emergency department visits related to such chronic health condition in the previous 12 months
- High-risk pregnant persons
See manual for covered billing codes.
Prior authorization will be required for coverage of these services. Please reference the updated Telehealth Supplement, and its associated references, for FFS policies, service authorization criteria, quantity limits and billing processes. MCOs will adopt equivalent service authorization criteria and quantity limits as FFS.
SOURCE: VA Department of Medical Assistant Services. Bulletin Coverage of Remote Patient Monitoring/Update to Telehealth Services Supplement. (Mar. 2022). (Accessed Apr. 2022).
PROVIDER LIMITATIONS
The Provider must have an established relationship with the member receiving the RPM service, including at least one visit in the last 12 months (which can include the date RPM services are initiated).
The member receiving the RPM service must fall into one of the following five populations, with duration of initial service authorization in parentheses as per below:
-
-
- Medically complex patient under 21 years of age (6 months);
- Transplant patient (6 months);
- Post-surgical patient (up to 3 months following the date of surgery);
- Patient with a chronic health condition who has had two or more hospitalizations or emergency department visits related to such chronic health condition in the previous 12 months (6 months); and/or a
- High-risk pregnant person (6 months).
All service authorization criteria outlined in the DMAS Form “DMAS-P268” are met prior to billing the following CPT/HCPCS codes:
- Physiologic Monitoring: 99453, 99454, 99457, 99458, and 99091
- Therapeutic Monitoring: 98975, 98976, 98977, 98980, and 98981
- Self-Measured Blood Pressure: 99473, 99474
Providers must meet the criteria outlined in the DMAS Form “DMAS-P268” and submit their requests to the DMAS service authorization contractor by direct data entry (DDE) via their provider portal. See Appendix D of the Physician/Practitioner manual for details on the current service authorization contractor and accessing the provider portal.
Service authorization requests must be submitted at least 30 days prior to the scheduled date of initiation of services.
Reauthorizations will be permitted for select services, as appropriate and as per criteria in the DMAS Form “DMAS-P268”.
OTHER RESTRICTIONS
Equipment utilized for Remote Patient Monitoring must meet the Food and Drug Administration (FDA) definition of a medical device as described in section 201(h) of the Federal, Food, Drug and Cosmetic Act.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Physician/Practitioner) pgs 8 (Mar. 2022) (Accessed Apr. 2022).
Last updated 04/09/2022
Store and Forward
POLICY
Store-and-forward means the asynchronous transmission of a member’s medical information from an originating site to a health care Provider located at a distant site. A member’s medical information may include, but is not limited to, video clips, still images, x-rays, laboratory results, audio clips, and text. The information is reviewed at the Distant Site without the patient present with interpretation or results relayed by the distant site Provider via synchronous or asynchronous communications.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 2 (Mar. 2022) (Accessed Apr. 2022).
ELIGIBLE SERVICES/SPECIALTIES
Refer to the telehealth supplement and billing manual for a full list of CPT and HCPCS codes reimbursable by Virginia Medicaid, including those through store and forward.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Mar. 2022) & VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual, Physician/Practitioner. Billing Instructions, p. 20-25 (July 2021) (Accessed Apr. 2022).
GEOGRAPHIC LIMITS
The originating site is the location of the member at the time the service is rendered, or the site where the asynchronous store-and-forward service originates (i.e., where the data are collected). Examples of originating sites include: medical care facility; Provider’s outpatient office; the member’s residence or school; or other community location (e.g., place of employment).
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 2 (Mar. 2022) (Accessed Apr. 2022).
TRANSMISSION FEE
Facility fee is only available for synchronous telehealth services.
SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), p. 6 (Mar. 2022) (Accessed Apr. 2022).
