Washington

Last updated 08/27/2022

Consent Requirements

Consent for care via the modality used is required for documentation by the distant site.

Consent must be documented in the client record.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide. Telemedicine Policy and Billing, p. 8, 12 (Aug. 2022). (Accessed Aug. 2022).

Written informed consent is obtained from the client that store and forward technology will be used and who the consulting provider is.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 353 (Aug. 2022). WA State Health Care Authority. Medicaid Provider Guide. Telemedicine Policy and Billing, p. 14 (Aug. 2022). (Accessed Aug. 2022).

Informed consent documentation is required for remote patient monitoring services.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 362 (Aug. 2022). (Accessed Aug. 2022).

Managed Care and Behavioral Health Administrative Service Organizations

If a provider intends to bill a patient or a managed health care system for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered. The authority may submit information on any potential violations of this subsection to the appropriate disciplining authority.

If the commissioner has cause to believe that a provider has engaged in a pattern of unresolved violations obtaining consent (as required above) the commissioner may submit information to the appropriate disciplining authority for action. Prior to submitting information to the appropriate disciplining authority, the commissioner may provide the provider with an opportunity to cure the alleged violations.  See text for additional information.

SOURCE: Revised Code of Washington 71.24.335 & 74.09.325. (Accessed Aug. 2022).

Last updated 08/26/2022

Definitions

“Telemedicine” means the delivery of health care or behavioral health services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. For purposes of this section only, “telemedicine” includes audio-only telemedicine, but does not include facsimile, or email.

SOURCE: RCW 74.09.325(9)(k) & RCW 71.24.335(9)(i). (Accessed Aug. 2022).

“Telemedicine is when health care practitioners use HIPAA-compliant interactive real-time audio and video telecommunications (including web-based applications) or store-and-forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.”

SOURCE: WA Admin. Code Sec. 182-531-1730 (Accessed Aug. 2022).

• Email and facsimile transmissions
• Installation or maintenance of any telecommunication devices or systems
• Purchase, rental, or repair of telemedicine equipment

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School Based Health Care Services, p. 36-37 (July 2022). (Accessed Aug. 2022).

Telehealth is the use of telecommunications technologies to support distant MSS/ICM covered services. HCA allows telehealth modalities to provide MSS/ICM services in lieu of an in-person visit, and the visits may be provided as audio-only (telephone calls).

SOURCE: Maternity Support Services and Infant Case Management, p. 10 (Aug. 2022), (Accessed Aug. 2022).

Last updated 08/27/2022

Email, Phone & Fax

Effective August 1, 2022

HCA will pay for audio-only services for specific billing codes when provided and billed as directed in HCA provider billing guides. This shift in billing practice comes because of 2021 legislation (HB 1196), which requires coverage at parity of audio-only telemedicine that can be safely and effectively provided according to generally accepted health care practices and standards. HCA has published a list of billing codes that are payable when services are provided by audio-only telemedicine (over the phone). The new list of audio-only codes is published on HCA’s Provider billing guides and fee schedules webpage (scroll down to Telehealth under Billing guides and fee schedules).

Apple Health (Medicaid) policies require the appropriate audio-only modifiers (93 or FQ). Information related to specific service areas and billing guidelines includes the following:

• For Service Encounter Reporting Instructions (SERI) and Part II of the Mental Health Billing Guide, providers will use modifier FQ
• For Part 1 of the Mental Health Billing Guide, providers will use modifier 93
• All other physical health programs will use modifier 93

For services that are partially audio/visual and partially audio-only, a service is considered audio-only if 50% or more of the service was provided via audio-only telemedicine.

Providers must obtain consent before rendering audio-only services and document the consent in the client record.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Telemedicine Policy and Billing, p. 12 (Aug. 2022). (Accessed Aug. 2022).

The authority shall adopt rules regarding medicaid fee-for-service reimbursement for services delivered through audio-only telemedicine.  The rules must establish a manner of reimbursement for audio-only telemedicine that is consistent with RCW 74.09.325. The rules shall require rural health clinics to be reimbursed for audio-only telemedicine at the rural health clinic encounter rate.

“Audio-only telemedicine” means the delivery of health care services through the use of audio-only technology, permitting real-time communication between a patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.  It does not include:

• The use of facsimile or email; or
• The delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results.

SOURCE: RCW 74.09.327 (Accessed Aug. 2022).

Managed Care & Behavioral Health Administrative Services Organizations

“Audio-only telemedicine” means the delivery of health care services through the use of audio-only technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.  It does not include:

• The use of facsimile or email; or
• The delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results.

Upon initiation or renewal of a contract with the Washington state health care authority to administer a medicaid managed care plan, a managed health care system shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology if … Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.

“Established relationship” means the covered person has had at least one in-person appointment within the past year with the provider providing audio-only telemedicine or with a provider employed at the same clinic as the provider providing audio-only telemedicine or the covered person was referred to the provider providing audio-only telemedicine by another provider who has had at least one in-person appointment with the covered person within the past year and has provided relevant medical information to the provider providing audio-only telemedicine.

A rural health clinic shall be reimbursed for audio-only telemedicine at the rural health clinic encounter rate.

If a provider intends to bill a patient or a managed health care system for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered. The authority may submit information on any potential violations of this subsection to the appropriate disciplining authority, as defined in RCW 18.130.020.

Effective June 9, 2022: Established relationship means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and, for health care services included in the essential health benefits category of mental health and substance use disorder services, including behavioral health treatment:

• The covered person has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or
• The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine.

SOURCE: Revised Code of Washington 74.09.325 & 71.24.335, as amended by HB 1821 (2022 Legislative Session). (Accessed Aug. 2022).

Effective June 9, 2022: For any other health care service:

• The covered person has had, within the past two years, at least one in-person appointment with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or
• The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past two years, at least one in-person appointment with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine.

SOURCE: Revised Code of Washington 74.09.325, as amended by HB 1821 (2022 Legislative Session). (Accessed Aug. 2022).

School-Based Health Services

The SBHS program reimburses for some services when provided through audio-only telemedicine (i.e., telephone service delivery).

To indicate that the service was provided through audio-only telemedicine (i.e., telephone service delivery with no visual component), school districts must submit claims for telemedicine services using either place of service (POS) 02 or POS 10 and must add modifier 93 to the claim to indicate services were provided through audio-only telemedicine. When billing for audio-only telemedicine through the SBHS program, the school district always submits a claim on behalf of both the originating and distant site.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, SBHS Billing, p. 37-39 (July 2022). (Accessed Aug. 2022).

Obstetrical Services

HCA allows obstetrical services to be provided via audio-only. Audio-only visits for pregnant clients must:

• Be utilized only when clinically appropriate for the individual client, based on current clinical guidance and standards of care from ACOG and AAFP.
• Not be used when client circumstances call for an in-person assessment or procedure.
• Be informed by client preference. Clients must have input on and choice regarding how services are delivered.
• Have documentation that complies with HCA’s telemedicine policies. Must include start and stop time of audio-only interaction.

HCA does not pay for abortion services provided via audio-only telemedicine.

See manual for audio-only billing instructions relative to global OB care and unbundled obstetrical care.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 214-215, 218-221 (Aug. 2022). (Accessed Aug. 2022).

Comprehensive assessment and care planning for persons living with cognitive impairment

Face-to-face visits via an in-person or audio-visual encounter are allowed, but HCA does not allow telephonic and email encounters.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 72 (Aug. 2022). (Accessed Aug. 2022).

Applied Behavior Analysis (ABA) Services

The following services are not paid for as telemedicine:

• Email, telephone, and facsimile transmissions.
• Installation or maintenance of any telecommunication devices or systems.
• Purchase, rental, or repair of telemedicine equipment.
• Home health monitoring.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide. ABA Program Billing, p. 32 (Aug. 2022). (Accessed Aug. 2022).

Telephone Services

HCA pays for telephone services when used by a physician to report and bill for episodes of care initiated by an established patient (i.e., someone who has received a face-to-face service from you or another physician of the same specialty in your group in the past three years) or by the patient’s guardian.  See manual for codes and additional requirements.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 53 (Aug. 2022). (Accessed Aug. 2022).

Teledentistry

The agency does not cover email or facsimile transmissions as teledentistry services.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Dental-Related Services, p. 75, (Aug. 2022). (Accessed Aug. 2022).

FACILITY FEE

HCA does not pay an originating site facility fee for audio-only services.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Telemedicine Policy and Billing, p. 9 (Aug. 2022); WA State Health Care Authority, Medicaid Provider Guide, SBHS Billing, p. 37-39 (July 2022). (Accessed Aug. 2022).

A hospital that is an originating site or distant site for audio-only telemedicine may not charge a facility fee.

SOURCE: RCW 70.41.530, as added by HB 1708 (2022 Session). (Accessed Aug. 2022).

Last updated 08/26/2022

Live Video

POLICY

Washington Health Care Authority (HCA) reimburses medically necessary covered services through telemedicine when the service is provided by a Washington Apple Health provider and is within their scope of practice. The payment amount for the professional service provided through telemedicine by the provider at the distant site is equal to the current fee schedule amount for the service provided.

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 10, 11 (Aug. 2022) (Accessed Aug 2022)

Managed Care 

Upon initiation or renewal of a contract with the Washington state health care authority to administer a Medicaid managed care plan, a managed health care system shall reimburse a provider for a health care service provided to a covered person through telemedicine at the same rate as if:

• The medicaid managed care plan in which the covered person is enrolled provides coverage of the health care service when provided in person by the provider;
• The health care service is medically necessary;
• The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act in effect on January 1, 2015;
• The health care service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information; and
• Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.

A managed health care system shall reimburse a provider for a health care service provided to a covered person through telemedicine the same amount of compensation the managed health care system would pay the provider if the health care service was provided in person by the provider.

Hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate an amount of compensation for telemedicine services that differs from the amount of compensation for in-person services.

A managed health care system may subject coverage of a telemedicine or store and forward technology health service to all terms and conditions of the plan in which the covered person is enrolled including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable health care service provided in person.

SOURCE: RCW 74.09.325. (Accessed Aug. 2022).

Behavioral Health Services

• The behavioral health administrative services organization or managed care organization in which the covered person is enrolled provides coverage of the behavioral health service when provided in person by the provider;
• The behavioral health service is medically necessary; and
• Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.

SOURCE: RCW 71.24.335 (Accessed Aug. 2022).

If the service is provided through store and forward technology there must be an associated visit between the covered person and the referring provider. Nothing in this section prohibits the use of telemedicine for the associated office visit.

SOURCE: RCW 71.24.335; WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 14 (Aug. 2022)

ELIGIBLE SERVICES/SPECIALTIES

The agency reimburses medically necessary covered services through telemedicine when the service is provided by a Washington Apple Health (Medicaid) provider and is within their scope of practice.

Submit claims for telemedicine services using the appropriate CPT® or HCPCS code for the professional service. Use place of service (POS) 02 or 10 to indicate that a billed service was furnished as a telemedicine service from a distant site.

When billing with POS 02 or 10:

• Add modifier 95 if the distant site is designated as a nonfacility.
• Nonfacility providers must add modifier 95 to the claim to receive the nonfacility payment.

HCA discontinued the use of modifier GT for claims submitted for professional services (services billed on a CMS-1500 claim form, when submitting paper claims). Distant site practitioners billing for telemedicine services under the Critical Access Hospital (CAH) optional payment method must use modifier GT.

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 10, 11 (Aug. 2022) (Accessed Aug. 2022).

School Based Services

HCA covers telemedicine when it is used to substitute for an in-person, face-to-face, hands-on encounter for only those services specifically listed in this billing guide. In order for a school district to receive reimbursement for telemedicine, the provider furnishing services through telemedicine must be enrolled as a servicing provider under the school district’s ProviderOne account. Services provided by nonlicensed school staff must be billed under the supervising provider’s NPI in ProviderOne.

To indicate that the service was provided through HIPAA-compliant audio/visual telemedicine, school districts must submit claims for telemedicine services using either place of service (POS) 02 or POS 10 and enter modifier 95 on any claims for services provided through audio/visual telemedicine. When billing for telemedicine through the SBHS program, the school district always submits a claim on behalf of both the originating and distant site.

Telemedicine claims must include one of the following modifiers based on the platform used to deliver the service: 93 or 95.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School-Based Health Services, p. 37-38 (July 2022). (Accessed Aug. 2022).

Applied Behavior Analysis (ABA)

Eligible telemedicine services:

• Program supervision when the client is present
• Family/caregiver training, which does not require the client’s presence
• Speech language pathology services when otherwise not available in person

The LBA may use telemedicine to supervise the CBT’s delivery of ABA services to the client, the family, or both. LBAs who use telemedicine are responsible for determining if telemedicine can be performed without compromising the quality of the caregiver training, or the outcome of the ABA therapy treatment plan.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Applied Behavior Analysis, p. 31 (Aug. 2022) & WAC 182-531A-1200. (Accessed Aug. 2022).

Teledentistry

Teledentistry can be delivered through a synchronous or asynchronous method.  The agency covers teledentistry as a substitute for an in-person, face-to-face, hands-on encounter when medically necessary, within the scope of practice of the performing agency-contracted providers, and Department of Health teledentistry guidelines.

A dentist or authorized dental provider may delegate allowable tasks to Washington State Registered Dental Hygienists and Expanded Function Dental Assistants through teledentistry.  Delegation of tasks must be under general supervision. Teledentistry does not meet the definition of close supervision.

See manual for acceptable CPT codes.

SOURCE: WA State Health Care Authority, Medicaid Provider. Dental-Related Services, p. 75. (Aug. 2022). (Accessed Aug. 2022).

Mental Health Services

Drug monitoring must be provided during an in-person visit with the client, unless it is part of a qualified telemedicine visit.

SOURCE: WA State Health Care Authority, Medicaid Provider. Mental Health Services, p. 49. (Aug. 2022). (Accessed Aug. 2022).

Home Health Services

The face-to-face encounter requirements of this section may be met using telemedicine or telehealth services.

SOURCE: WA Admin Code 182-551-2040. (Accessed Aug. 2022).

Comprehensive assessment and care planning for persons living with cognitive impairment

Face-to-face visits via an in-person or audio-visual encounter are allowed, but HCA does not allow telephonic and email encounters.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 72 (Aug. 2022). (Accessed Aug. 2022).

Abortion

Medical abortion services provided via telemedicine to a client who does not receive ultrasound(s) and laboratory studies from the medical abortion provider are not eligible for the HCPCS S0199 bundled payment.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 218 (Aug. 2022). (Accessed Aug. 2022).

Prenatal Genetic Counseling

Medicaid covers prenatal genetic counseling via in-person or audio-visual telemedicine encounters.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 186 (Aug. 2022). (Accessed Aug. 2022).

Obstetrical Services

HCA allows obstetrical services to be provided via telemedicine. When billing for audio-visual telemedicine, use the place of service (POS) relevant to the service provided on the date of service or the last date of service for a global or bundled code. For example:

• If the service was provided in-person in an office setting, use POS 11 (office).
• If the service was provided via audio-visual telemedicine, use either POS 02 (telehealth) or 10 (telehealth provided in patient home), whichever is appropriate
• If the service was provided via audio-only telemedicine, refer to HCA’s Telemedicine policy and billing document

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 214-215, 218-221 (Aug. 2022). (Accessed Aug. 2022).

Maternal Support Services (MSS)

Telehealth is the use of telecommunications technologies to support distant MSS/ICM covered services. HCA allows telehealth modalities to provide MSS/ICM services in lieu of an in-person visit, and the visits may be provided as audio-only (telephone calls). Refer to HCA’s Provider billing guides and fee schedules webpage, under Telehealth, for more information.

SOURCE: WA State Health Care Authority, Maternity Support Services and Infant Case Management Billing Guide, p 10 (Aug. 2022). (Accessed Aug. 2022).

Federally Qualified Health Center (FQHCs)

A face-to-face or telehealth visit between a client and a qualified FQHC provider (e.g., a physician, physician assistant, or advanced registered nurse practitioner) who exercises independent judgment when providing services that qualify for an encounter rate.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Rural Health Clinics, p. 9, (Aug. 2022); Federally Qualified Health Centers, p. 9 (Aug. 2022), (Accessed Aug. 2022).

ELIGIBLE PROVIDERS

Rural Health Clinics (RHCs) & FQHCs

RHCs & FQHCs are authorized to serve as an originating site for telemedicine services. RHCs and FQHCs may receive the encounter rate when billing as a distant site provider if the service being billed is encounter eligible. Clients enrolled in an agency-contracted MCO must contact the MCO regarding whether or not the plan will authorize telemedicine coverage.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Rural Health Clinics, p. 46, (Aug. 2022); Federally Qualified Health Centers, p. 62. (Aug. 2022), (Accessed Aug. 2022).

School Based Health Care Services

Under the SBHS program, HCA pays for services provided through telemedicine as outlined in this billing guide. Licensed providers, licensed assistants, compact license holders, interim permit holders, and non-licensed school staff practicing under the supervision of a licensed provider may provide SBHS through telemedicine.

In order for a school district to receive reimbursement for telemedicine, the provider furnishing services through telemedicine must be enrolled as a servicing provider under the school district’s ProviderOne account. Services provided by nonlicensed school staff must be billed under the supervising provider’s NPI in ProviderOne.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School-Based Health Services, p. 36-37 (July 2022). (Accessed Aug. 2022).

Tribal Health Program

An encounter can be conducted face-to-face or via real-time telemedicine.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Tribal Health Program, p. 19, (July 2022), (Accessed Aug. 2022).

Kidney Centers and Ambulatory Surgery Centers

For kidney centers or ambulatory surgery centers to bill for telemedicine services, either the client or the provider must be physically present at the facility at the time the service was rendered.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 10 (Aug. 2022)

ELIGIBLE SITES

An originating site and a distant site must be located within the continental United States, Hawaii, District of Columbia, or any United States territory (e.g., Puerto Rico). Specific documentation requirements apply to both originating and distant sites. See the Telemedicine Policy and Billing Guide for more information.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 8-10 (Aug. 2022)

Approved Originating Sites

• Clinics;
• Community mental health center/chemical dependency settings;
• Dental offices;
• Federally qualified health center;
• Home or any location determined appropriate by the individual receiving the service;
• Hospitals—inpatient or outpatient;
• Neurodevelopmental centers;
• Physician’s or other health professional’s office;
• Renal dialysis centers, except an independent renal dialysis center;
• Rural health clinic;
• Schools; or
• Skilled nursing facility

SOURCE: WAC 182-531-1730.(3) (Accessed Aug. 2022).

Managed Care

The following are eligible originating sites.

1. Hospital;
2. Rural health clinic;
3. Federally qualified health center;
4. Physician’s or other health care provider’s office;
5. Licensed or certified behavioral health agency;
6. Skilled nursing facility;
7. Home or any location determined by the individual receiving the service; or
8. Renal dialysis center, except an independent renal dialysis center.

SOURCE: RCW 74.09.325. (Accessed Aug. 2022).

School-Based Health Care Services (SBHS)

The school district must submit a claim on behalf of both the originating and distant site.  The location of the student and provider must be documented. The SBHS program allows the following approved originating sites:

• The school
• The home, daycare, or any location determined appropriate by the students or parents

See manual for specific scenarios and appropriate modifiers.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School Based Health Care Services, p. 37-38 (July 2022), (Accessed Aug. 2022).

Applied Behavior Analysis (ABA) Services

For the purposes of ABA services, an originating site is:

• For therapy, where the client is located.
• For caregiver training, where the caregiver is located.

The distant site is the physical location where the lead behavior analysis therapist (LBAT) is located during the telemedicine session. If a separately identifiable service for the client is performed on the same day as the telemedicine service, documentation for both services must be clearly and separately identified in the client’s medical record.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide. ABA Services, p. 31 (Aug. 2022). (Accessed Aug. 2022).

GEOGRAPHIC LIMITS

A managed health care system may not distinguish between originating sites that are rural and urban in providing the coverage required in subsection (1) of this section.

SOURCE: RCW 74.09.325 (Accessed Aug. 2022).

FACILITY/TRANSMISSION FEE

Originating sites that are enrolled with HCA to provide services to HCA clients and bill HCA may be paid a facility fee for infrastructure and client preparation. Originating site facility fees are not paid for audio-only or store-and-forward telemedicine services.

Facility fees are available for originating sites, except hospitals (inpatient services), skilled nursing facilities, homes or other locations receiving payment for the client’s room and board. HCA does not pay an originating site facility fee if the site is part of the same entity as the distant site or if the provider is employed by the same entity as the distant site, nor does HCA pay an originating site facility fee to the client in any setting.

Eligible originating sites explicitly listed for the facility fee include:

• Hospital outpatient
• Critical access hospitals
• FQHCs and RHCs
• Physicians or other health professional office
• Other settings, when approved as an originating site

See manual for specific billing instructions for each.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 9-10 (Aug. 2022)

A hospital that is an originating site or distant site for audio-only telemedicine may not charge a facility fee.

SOURCE: RCW 70.41.530 as added by HB 1708 (2022 Session). (Accessed Aug. 2022).

Managed Care

The following eligible originating sites (besides #7) can charge a facility fee for infrastructure and preparation of the patient.

1. Hospital;
2. Rural health clinic;
3. Federally qualified health center;
4. Physician’s or other health care provider’s office;
5. Licensed or certified behavioral health agency;
6. Skilled nursing facility;
7. Home or any location determined by the individual receiving the service; or
8. Renal dialysis center, except an independent renal dialysis center.

Reimbursement for a facility fee must be subject to a negotiated agreement between the originating site and the managed health care system. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in subsection (3) of this section may not charge a facility fee.

SOURCE: RCW 74.09.325. (Accessed Aug. 2022).

FQHCs/RHCs

FQHCs and Rural Health Clinics that serve as an originating site for telemedicine services are paid an originating site facility fee. Charges for the originating site facility fee may be included on a claim, but the originating site facility fee may not be included on the cost report.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide Rural Health Clinics, p. 46, (Aug. 2022) & Federally Qualified Health Centers, p. 62 (Aug. 2022). (Accessed Aug. 2022).

School-Based Health Care Services (SBHS)

To receive payment for the telemedicine fee (HCPCS code Q3014), the student must be located at the school and a corresponding procedure code must be billed for the same date of service. Treatment notes must clearly reflect when services were provided through telemedicine. HCA does not reimburse for the telemedicine facility fee for audio-only services.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, School Based Health Care Services, p. 38-39 (July 2022), (Accessed Aug. 2022).

Dental Related Services

The facility fee is included in the CDT code. There is no separate facility fee for teledentistry.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Dental Services, p. 76 (Aug. 2022). (Accessed Aug. 2022).

Abortion

When telemedicine is used to provide HCPCS S0199 bundled services, HCA does not pay any additional originating facility fees.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 218 (Aug. 2022). (Accessed Aug. 2022).

Tribal Health

The telemedicine facility fee (HCPCS code Q3014) is not included in the encounter rate, but it is payable separately from the encounter rate at the applicable rate in the fee schedule. The telemedicine facility fee must be billed on a separate claim from the encounter claim to avoid including the item in the encounter payment.

SOURCE: WA State Health Care Authority, Tribal Health Billing Guide, p. 21 (July 2022). (Accessed Aug. 2022).

Last updated 08/27/2022

Miscellaneous

Telemedicine Documentation Requirements

Distant site:

• Specification of the telehealth modality that was used (e.g., visit was conducted via HIPAA-compliant real-time audio/visual)
• Verification that telemedicine was clinically appropriate for this service
• Whether any assistive technologies were used
• The location of the client
• The names and credentials (MD, ARNP, RN, PA, etc.) of all provider personnel involved in the telemedicine visit
• The people who attended the appointment with the client (family, friend, caregiver)
• The start and end times of the health care service provided by telemedicine
• Consent for care via the modality that was used

Originating site:

• Specification of the telehealth modality that was used (e.g., visit was conducted via HIPAA-compliant real-time audio/visual)
• If there are staff involved in providing the service list the names and credentials (e.g., MD, ARNP, PA, etc.) of all provider personnel involved in the telemedicine visit
• Any medical service provided (e.g., vital signs, weight, etc.)
• The start and end times of the health care service provided by telemedicine

SOURCE: WA State Health Care Authority. Medicaid Provider Guide. Telemedicine Policy and Billing, p. 8 (Aug. 2022) (Accessed Aug. 2022).

Use place of service (POS) 02 or 10 to indicate that a billed service was furnished as a telemedicine service from a distant site.

When billing with POS 02 or 10:

• Add modifier 95 if the distant site is designated as a nonfacility.
• Nonfacility providers must add modifier 95 to the claim to receive the nonfacility payment.

HCA discontinued the use of modifier GT for claims submitted for professional services (services billed on a CMS-1500 claim form, when submitting paper claims). Distant site practitioners billing for telemedicine services under the Critical Access Hospital (CAH) optional payment method must use modifier GT.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide. Telemedicine Policy and Billing, p. 11 (Aug. 2022) (Accessed Aug. 2022).

Applied Behavioral Analysis (ABA) Services

If a separately identifiable service for the client is performed on the same day as the telemedicine service, documentation for both services must be clearly and separately identified in the client’s medical record.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, ABA Services, p. 31 (Aug. 2022). (Accessed Aug. 2022).

School-Based Health Services

The documentation requirements are the same as those listed in the documentation section of this billing guide, as well as the following:

• Documentation that the service was provided through telemedicine
• Provider must indicate whether the service was delivered through audio/visual or audio-only telemedicine
• The location of the student
• The location of the provider

The SBHS program uses two telemedicine modifiers. Telemedicine claims must include one of the following modifiers based on the platform used to deliver the service. Only use modifier 93 when providing services through audio-only telehealth (i.e., telephone with no visual component). Use with either POS 02 or POS 10. Only use telemedicine modifier 95 when providing services through HIPAA compliant audio/visual telehealth. Use with either POS 02 or POS 10.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, SBHS Billing, p. 37 & 39 (July 2022). (Accessed Aug. 2022).

Telemedicine Best Practices

When conducting telemedicine services, it is important to ensure that the standard of care for telemedicine is the same as that for an in-person visit, providing the same health care service. Refer to the Department of Health for requirements from various commissions (e.g., Medical Commission, Nursing Commission, etc.).

Best practices may include, but are not limited to, the following:

• Consider the client’s resources when deciding the best platform to provide telemedicine services.
• Test the process and have a back-up plan; connections can be disrupted with heavy volume. Communicate a back-up plan in the event the technology fails.
• Introduce yourself, including what your credential is and what specialty you practice. Show a badge when applicable.
• Ask the client their name and verify their identity. Consider requesting a photo ID when applicable/available.
• Inform clients of your location and obtain the location of clients. Include this information in documentation.
• Inform the client of how the client can see a clinician in-person in the event of an emergency or as otherwise needed.
• Inform clients they may want to be in a room or space where privacy can be preserved during the conversation.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide. Telemedicine Policy and Billing, p. 6 (Aug. 2022) (Accessed Aug. 2022).

Last updated 08/26/2022

Out of State Providers

No Reference Found

Last updated 08/26/2022

Overview

Telemedicine is covered by the Department. Washington Medicaid (Apple Health) reimburses for live video, store-and-forward, and remote patient monitoring under certain circumstances. The Department recently began covering audio-only services for specific billing codes as well.

SOURCE: WA Admin. Code Sec. 182-531-0100. WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide (Aug. 2022) & WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., RPM, p. 90 (Aug. 2022). WA State Health Care Authority, Medicaid Provider Bulletin, Audio-Only Telemedicine (Apr. 2022); WA State Health Care Authority. Telehealth Services Billing Guide Audio-Only Supplement. (Accessed Aug. 2022).

Last updated 08/26/2022

Remote Patient Monitoring

POLICY

Certain service procedure codes are covered for remote patient monitoring (RPM) when specific medical necessity criteria are met.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 90-92 (Aug. 2022). (Accessed Aug. 2022).

Home Health Services

“Telemedicine means the use of tele-monitoring to enhance the delivery of certain home health skilled nursing services through:

• The collection of clinical data and the transmission of such data between a patient at a distant location and the home health provider through electronic processing technologies. Objective clinical data that may be transmitted includes, but is not limited to, weight, blood pressure, pulse, respirations, blood glucose, and pulse oximetry; or
• The provision of certain education related to health care services using audio, video, or data communication instead of a face-to-face visit.”

SOURCE: WA Admin. Code Sec. 182-551-2010. (Accessed Aug. 2022).

HCA covers the delivery of home health services through telemedicine for clients who have been diagnosed with an unstable condition who may be at risk for hospitalization or a more costly level of care.  See manual for codes.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 28, (July 2022). (Accessed Aug. 2022).

CONDITIONS

Specific medical necessity criteria must be met for RPM coverage, including disease-specific criteria. In addition to meeting other defined general criteria, the client must have a qualifying diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or hypertension.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 91 (Aug. 2022). (Accessed Aug. 2022).

Home Health Services

The client must have a diagnosis or diagnoses where there is a high risk of sudden change in medical condition which could compromise health outcomes. See manual for specific does to bill.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 28. (July 2022). (Accessed Aug. 2022).

PROVIDER LIMITATIONS

FQHCs/RHCs

CPT® code 99453 is encounter-eligible when performed by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) encounter-qualified provider. Other RPM procedure codes are not RHC- or FQHC-encounter eligible.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 92 (Aug. 2022). (Accessed Aug. 2022).

OTHER RESTRICTIONS

Specific medical necessity criteria must be met for RPM coverage, including the following:

• Client-specific criteria. The client must exhibit at least one of the following risk factors in each category:
  • Health care utilization:
    • Two or more hospitalizations in the prior 12-month period
    • Four or more emergency department admissions in the prior 12-month period
  • Other risk factors that present challenges to optimal care:
    • Limited or absent informal support systems
    • Living alone or being home alone for extended periods of time
    • A history of care access challenges
    • A history of consistently missed appointments with health care providers
• Device-specific criteria. The device must have both of the following:
  • Capability to directly transmit patient data to provider
  • An internet connection and capability to use monitoring tools

Informed consent documentation requirements and quantitative limits also apply to RPM services.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 91-92 (Aug. 2022). (Accessed Aug. 2022).

Home Health Services

HCA pays for one telemedicine interaction, per eligible client, per day, based on the ordering licensed practitioner’s home health plan of care.

To receive payment for the delivery of home health services through telemedicine, the services must involve:

• A documented assessment, identified problem, and evaluation, which includes:
  • Assessment and monitoring of clinical data including, but not limited to, vital signs, pain levels and other biometric measures specified in the plan of care. Also included is an assessment of response to previous changes in the plan of care.
  • Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care

• Implementation of a documented management plan through one or
  more of the following:
  • Education regarding medication management as appropriate, based on the findings from the telemedicine encounter
  • Education regarding other interventions as appropriate to both the patient and the caregiver
  • Management and evaluation of the plan of care, including changes in visit frequency or the addition of other skilled services
  • Coordination of care with the ordering licensed provider regarding findings from the telemedicine encounter
  • Coordination and referral to other medical providers as needed
  • Referral to the emergency room as needed

HCA does not pay for the purchase, rental, repair, or maintenance of telemedicine equipment and associated costs of operation of telemedicine equipment.

HCA does not require prior authorization for the delivery of home health services through telemedicine.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 28-29, (July 2022). (Accessed Aug. 2022).

Home health monitoring is not covered in Applied Behavior Analysis Program.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Applied Behavior Analysis, p. 30 (Aug. 2022). (Accessed Aug. 2022).

Last updated 08/26/2022

Store and Forward

POLICY

Store and Forward is the transmission of medical information to be reviewed later by a physician or practitioner at a distant site. A client’s medical information may include, but is not limited to, video clips, still images, x-rays, laboratory results, audio clips, and text. The physician or practitioner at the distant site reviews the case without the client present.

HCA pays for Store and Forward when all the following conditions are met:

• It is associated with an office visit between the eligible client and the referring health care provider. The associated visit can be done in person or via asynchronous telemedicine and include one or more of the following types of information: video clips, still images, x-rays, MRIs, electrocardiograms and electroencephalograms, laboratory results, audio clips, and text.
• The visit results in a documented care plan that is communicated back to the referring provider.
• The transmission of protected health information is HIPAA-compliant.
• Written informed consent is obtained from the client that Store and Forward technology will be used and who the consulting provider is.

If the consultation results in a face-to-face visit in person or via telemedicine with the specialist within 60 days of the Store and Forward consult, HCA does not pay for the Store and Forward consultation.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 14 (Aug. 2022). (Accessed Aug. 2022).

“Store and forward technology” means use of an asynchronous transmission of a covered person’s medical information from an originating site to the health care provider at a distant site which results in medical diagnosis and management of the covered person, and does not include the use of audio-only telephone, facsimile, or email.

SOURCE: RCW 74.09.325; WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 5 (Aug. 2022). (Accessed Aug. 2022).

Managed Care 

Upon initiation or renewal of a contract with the Washington state health care authority to administer a Medicaid managed care plan, a managed health care system shall reimburse a provider for a health care service provided to a covered person through telemedicine at the same rate as if:

• The medicaid managed care plan in which the covered person is enrolled provides coverage of the behavioral or health care service when provided in person by the provider;
• The health care service is medically necessary;
• The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act in effect on January 1, 2015;
• The health care service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information; and
• Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.

A managed health care system shall reimburse a provider for a health care service provided to a covered person through telemedicine the same amount of compensation the managed health care system would pay the provider if the health care service was provided in person by the provider.  For purposes of this section, reimbursement of store and forward technology is available only for those services specified in the negotiated agreement between the managed health care system and health care provider.

Hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate an amount of compensation for telemedicine services that differs from the amount of compensation for in-person services.

A managed health care system may subject coverage of a telemedicine or store and forward technology health service to all terms and conditions of the plan in which the covered person is enrolled including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable health care service provided in person.

SOURCE: RCW 74.09.325 (Accessed Aug. 2022).

Behavioral Health Administrative Services Organizations and Managed Care Organizations

• The behavioral health administrative services organization or managed care organization in which the covered person is enrolled provides coverage of the behavioral health service when provided in person by the provider;
• The behavioral health service is medically necessary; and
• Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.

Reimbursement of store and forward technology is available only for those services specified in the negotiated agreement between the behavioral health administrative services organization, or managed care organization, and the provider.

SOURCE: RCW 71.24.335 (Accessed Aug. 2022).

ELIGIBLE SERVICES/SPECIALTIES

Teledermatology

Teledermatology services must meet the following criteria:

• The teledermatology is associated with an office visit between the eligible client and the referring health care provider.
• The teledermatology is asynchronous telemedicine and the service results in a documented care plan, which is communicated back to the referring provider.
• The transmission of protected health information is HIPAA compliant.
• Written informed consent is obtained from the client that store and forward technology will be used and who the consulting provider is.
• GQ modifier required.

See manual for acceptable CPT/HCPCS codes.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 353. (Aug. 2022). (Accessed Aug. 2022).

HCA pays for Store and Forward for teledermatology. Teledermatology does not include single-mode consultations by telephone calls, images transmitted via facsimile machines, or electronic mail.

Teledermatology services provided via Store and Forward telecommunications system must be billed with modifier GQ. Bill only the portion(s) rendered from the distant site with modifier GQ. The sending provider bills as usual with the E/M and no modifier. The use of modifier GQ does not alter reimbursement for the CPT® or HCPCS code billed. You must use POS 02 to indicate the location where health services are provided through Store and Forward technology. POS 02 code does not apply to the originating site.

HCA denies claims submitted for Store and Forward services with POS code 02 if modifier GQ is not included.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 15-16 (Aug. 2022). (Accessed Aug. 2022).

Consultations—TB treatment services

Health departments may use a recorded video submitted by the client in place of the in-home visit or office visit. HCPCS code G2010 may be billed when this modality is used and the requirements of the code are met. HCPCS code G2010 is not Federally Qualified Health Center (FQHC) encounter-eligible

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 74 (Aug. 2022). (Accessed Aug. 2022).

Teledentistry

Teledentistry can be delivered through a synchronous or asynchronous method.  The agency covers teledentistry as a substitute for an in-person, face-to-face, hands-on encounter when medically necessary. For asynchronous teledentistry, the client’s dental clinical information is gathered at the originating site the information is sent via store-and-forward technology to a dentist or authorized dental provider (distant site) for review and subsequent intervention at a later point in time.

See manual for acceptable CPT codes.

SOURCE: WA State Health Care Authority, Medicaid Provider. Dental-Related Services, p. 75. (Aug. 2022). (Accessed Aug. 2022).

GEOGRAPHIC LIMITS

No Reference Found

TRANSMISSION FEE

The originating site for store-and-forward is not eligible to receive an originating site fee.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 14 (Aug. 2022). (Accessed Aug. 2022).