Washington

Disclaimer

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

At A Glance
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MEDICAID REIMBURSEMENT

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

PRIVATE PAYER LAW

  • Law Exists: Yes
  • Payment Parity: Yes

PROFESSIONAL REQUIREMENTS

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

STATE RESOURCES

  1. Medicaid Program: Washington Apple Health
  2. Administrator: Washington State Health Care Authority
  3. Regional Telehealth Resource Center: Northwest Regional Telehealth Resource Center
Disclaimer

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

Last updated 06/19/2024

Definition

“Telemedicine” means the delivery of health care 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.

“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.
For purposes of this section only, “audio-only telemedicine” 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.

“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: WA Rev. Code Sec. 48.43.735 & Sec. 41.05.700. (Accessed Jun. 2024).

“Telemedicine” means the delivery of health care services through the use of interactive audio and video technology or 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. For purposes of this chapter, “telemedicine” does not include facsimile, email, or text messaging, unless the use of text-like messaging is necessary to ensure effective communication with individuals who have a hearing, speech, or other disability.

“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.

“Audio-only telemedicine” does not include:

  • The use of facsimile, email, or text messages, unless the use of text-like messaging is necessary to ensure effective communication with individuals who have a hearing, speech, or other disability; 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: WA Admin. Code Sec. 284-170-130, as amended by Insurance Commissioner Permanent Rule. (Accessed Jun. 2024).

Last updated 06/20/2024

Parity

SERVICE PARITY

Services must be considered an essential health benefit under the ACA and be determined to be safely and effectively provided through telemedicine or store-and-forward.

Reimbursement of store and forward technology is available only for those covered services specified in the negotiated agreement between the health carrier and the health care provider.

SOURCE: RCW 48.43.735 & Sec. 41.05.700 & WAC 284-170-433. (Accessed Jun. 2024).


PAYMENT PARITY

A health carrier shall reimburse a provider for a health care service provided to a covered person through telemedicine the same amount of compensation the carrier 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.

SOURCE: RCW 48.43.735 & Sec. 41.05.700 & WAC 284-170-433. (Accessed Jun. 2024).

“Same amount of compensation” means providers are reimbursed by a carrier using the same allowed amount for telemedicine services as they would if the service had been provided in-person unless negotiation has been undertaken. Where consumer cost-sharing applies to telemedicine services, the consumer’s payment combined with the carrier’s payment must be the same amount of compensation, or allowed amount, as the carrier would pay the provider if the telemedicine service had been provided in person. Where an alternative payment methodology other than fee-for-service payment would apply to an in-person service, “same amount of compensation” means providers are reimbursed by a carrier using the same alternative payment methodology that would be used for the same service if provided in-person, unless negotiation has been undertaken.

SOURCE: WA Rev. Code Sec. 284-170-130. (Accessed Jun. 2024).

Last updated 06/20/2024

Requirements

Insurers (including employee health plans and Medicaid Managed Care) must reimburse a provider for services delivered through telemedicine or store-and-forward if:

  • The plan provides coverage when provided in-person;
  • 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 (ACA);
  • 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.

SOURCE: RCW 48.43.735 & Sec. 41.05.700, & WAC 284-170-433. (Accessed Jun. 2024).

“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 a locum tenens or other provider who is the designated back up or substitute provider for the provider providing audio-only telemedicine who is on leave and is not associated with an established medical group, clinic, or integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW; 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; A referral includes circumstances in which the provider who has had at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person participates in the audio-only telemedicine encounter with the provider to whom the covered person has been referred.

For any other health care service:

  • The covered person has had, within the past two years, at least one in-person appointment, or, until July 1, 2024, at least one real-time interactive appointment using both audio and video technology, with:
    • The provider providing audio-only telemedicine; or
    • 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
    • A locum tenens or other provider who is the designated back up or substitute provider for the provider providing audio-only telemedicine who is on leave and is not associated with an established medical group, clinic, or integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW; 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 or, until July 1, 2024, at least one real-time interactive appointment using both audio and video technology, with the covered person; and
    • Provided relevant medical information to the provider providing audio-only telemedicine.
    • A referral includes circumstances in which the provider who has had at least one in-person appointment, or, until July 1, 2024, at least one real-time interactive appointment using both audio and video technology, with the covered person participating in the audio-only telemedicine encounter with the provider to whom the covered person has been referred.

SOURCE: WA Rev. Code Sec. 284-170-130 as amended by Permanent Rule. (Accessed Jun. 2024).

“Established relationship” means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:

  • 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: RCW Sec. 41.05.700 & RCW 48.43.735, as amended by SB 5821 (2024 Legislative Session). (Accessed Jun. 2024).

Eligible Originating Sites:

  • Hospital
  • Rural health clinic
  • Federally qualified health center
  • Physician’s or other health care provider’s office
  • Licensed or certified behavioral health agency
  • Skilled nursing facility
  • Home or any location determined appropriate by the individual receiving the service
  • Renal dialysis center, except an independent renal dialysis center

Any originating site (other than #7 above) may charge a facility fee for infrastructure and preparation of the patient. Reimbursement for a facility fee must be subject to a negotiated agreement between the originating site and the health plan. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in the list above may not charge a facility fee.

The plan may not distinguish between originating sites that are rural and urban.

SOURCE: RCW 48.43.735 & Sec. 41.05.700 & WAC 284-170-433, (Accessed Jun. 2024).

An originating site that is a home or location determined appropriate by the individual receiving the service includes, but is not limited to: a pharmacy or a school-based health center. If the site chosen by the individual receiving service is in a state other than the state of Washington, a provider’s ability to conduct a telemedicine encounter in that state is determined by the licensure status of the provider and the provider licensure laws of the other state.

SOURCE: WAC 284-170-433, as added by Permanent Rule. (Accessed Jun. 2024).

Insurers offering a plan shall ensure that their benefits and services provided through electronic and information technology, including telehealth, are accessible to individuals with disabilities, unless doing so would result in undue financial and administrative burdens or a fundamental alteration in the nature of the health programs or activities. When undue financial and administrative burdens or a fundamental alteration exist, the issuer shall provide information in a format other than an electronic format that would not result in such undue financial and administrative burdens or a fundamental alteration but would ensure, to the maximum extent possible, that individuals with disabilities receive the benefits or services of the plan that are provided through electronic and information technology.

SOURCE:  WAC 284-43-5965 (Accessed Jun. 2024).

Language assistance services required under subsection (1) of this section must be provided free of charge, be accurate and timely, and protect the privacy and independence of the individual with limited-English proficiency, regardless of whether an associated health service is provided in person or through telehealth.

SOURCE:  WAC 284-43-5960 (Accessed Jun. 2024).

Printed and online provider directories must include information about any available telemedicine services, including any audio-only telemedicine services that are available, and specifically describe the services and how to access those services.

SOURCE: WAC 284-170-260. (Accessed Jun. 2024).

Every participating provider contract must, for health plans issued or renewed on or after July 25, 2021, and by July 1, 2022, ensure that access to telemedicine services is inclusive for those patients who may have disabilities or limited-English proficiency and for whom the use of telemedicine technology may be more challenging.

A health carrier is not required to reimburse:

  • An originating site for professional fees;
  • A provider for a health care service that is not a covered benefit under the plan; or
  • An originating site or provider when the site or provider is not a participating provider under the plan.

A health carrier may subject coverage of a telemedicine or store and forward technology health service under subsection (1) of this section 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.

A carrier may not deny, reduce, terminate or fail to make payment for the delivery of health care services using audio and visual technology solely because the communication between the patient and provider during the encounter shifted to audio-only due to unanticipated circumstances. In these instances, a carrier may not require a provider to obtain consent from the patient to continue the communication.

A carrier has no obligation to reimburse a provider for both an audio-visual and an audio-only encounter when both means of communication have been used during the encounter due to unforeseen circumstances.

Every participating provider contract must, effective July 25, 2021, provide that if a provider intends to bill a covered person or the covered person’s health plan for an audio-only telemedicine service, the provider must obtain patient consent from the covered person for the billing in advance of the service being delivered, consistent with the requirements of this subsection and state and federal laws applicable to obtaining patient consent.

A covered person’s consent must be obtained prior to initiation of the first audio-only encounter with a provider and may constitute consent to such encounters for a period of up to 12 months. If audio-only encounters continue beyond an initial 12-month period, consent must be obtained from the covered person for each prospective 12-month period.

Consent to be billed for audio-only telemedicine services must be obtained by the provider or auxiliary personnel under the general supervision of the provider.

A covered person may consent to a provider billing them or their health plan in writing or verbally. Consent to billing for an audio-only telemedicine encounter may be obtained and documented by the provider or auxiliary personnel under the general supervision of the provider as part of the process of making an appointment for an audio-only telemedicine encounter, recorded verbally as part of the audio-only telemedicine encounter record or otherwise documented in the patient record. Consent must be documented and retained by the provider for a minimum of five years. As needed, a carrier also may request documentation of the covered person’s consent as a condition of claim payment.

A patient may revoke consent granted under this subsection. Revocation of the patient’s consent must be communicated by the patient or their authorized representative to the provider or auxiliary personnel under the general supervision of the provider verbally or in writing and must be documented and retained by the provider for a minimum of five years. Once consent is revoked, the revocation must operate prospectively.

SOURCE: WAC 284-170-433, as added by Permanent Rule. (Accessed Jun. 2024).

Workers’ Compensation

Within the workers’ compensation system, when there is no approved examiner in the worker’s community or in a reasonably convenient location for the worker, the department or self-insurer may make alternate arrangements for the examination including, but not limited to, using telemedicine where appropriate.

The following exams may be conducted via telehealth:

  • Mental health;
  • Dermatology;
  • Speech when there is no documented hearing loss;
  • Kidney function;
  • Hematopoietic system;

The terms telehealth and telemedicine are used interchangeably and have the same requirements as in-person visits. Telemedicine may be appropriate to effectively conduct an independent medical exam when:

  • Face-to-face services by a qualified medical provider can be delivered through a real-time, two-way, audio video connection, and complies with all federal, state, and local rules and laws; and
  • A worker is able and willing to participate in an exam via telemedicine; and
  • The department or self-insured employer, and worker, have agreed a telemedicine IME is appropriate; these individuals should also agree to the location of the worker during the exam; and
  • The agreement is documented in the claim file; and
  • A physical or hands-on exam is not required.

Upon request of the department or self-insured employer and with the agreement of the worker, a telemedicine IME may be approved on a case-by-case basis for additional specialties not listed under subsection (1) of this section.

SOURCE: WAC 296-23-358; WAC 296-23-359, as added by Permanent Rule. (Accessed Jun. 2024).

Last updated 03/25/2024

Definitions

“Telemedicine” means the delivery of health care 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) WAC 182-501-0300 (1)(h), & RCW 71.24.335(9)(i). (Accessed Mar. 2024).

Telemedicine is the delivery of health care services using interactive audio and video technology, permitting real-time communication between the client at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. Telemedicine includes audio-only telemedicine, but does not include any of the following services:

  • Email and facsimile transmissions
  • Installation or maintenance of any telecommunication devices or systems
  • Purchase, rental, or repair of telemedicine equipment
  • Incidental services or communications that are not billed separately, such as communicating laboratory results

Telemedicine is an interaction between a healthcare provider who is physically located at the distant site and a client who is physically located at the originating site.

Audio-only telemedicine is the delivery of health care services using audio-only technology, permitting real-time communication between the client at the originating site and the provider, for the purposes of diagnosis, consultation, or treatment.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 7, 16 (Apr. 2024); WAC 182-501-0300 (2)(a). (Accessed Mar. 2024).

Telemedicine is when a health care provider uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) to deliver covered services that are within the provider’s scope of practice to a student at a site other than the site where the provider is located. The SBHS program also reimburses for some services when provided through audio-only telemedicine (i.e., telephone service delivery). HCA does not cover the following services provided through telemedicine:
  • 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. 35 (Oct. 2023). (Accessed Mar. 2024).

Home Health and Hospice

“Telehealth” means a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technology. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services.

“Telemedicine” means the delivery of health care services through the use of HIPAA-compliant, interactive audio and video technology (including web-based applications), permitting real-time communication between the patient and the agency provider, for the purpose of consultation, education, supervision, diagnosis, or treatment, as appropriate per scope of practice. “Telemedicine” also includes supervision of home health aide services to evaluate compliance with the plan of care and patient satisfaction with care. “Telemedicine” does not include the use of audio-only telephone, facsimile, electronic mail, or text messages.

SOURCE: WAC 246-335-510 & WAC 246-335-610. (Accessed Mar. 2024).

Last updated 03/28/2024

Email, Phone & Fax

HCA will pay for audio-only services for specific billing codes when provided and billed as directed in HCA provider billing guides. Refer to HCA’s Provider billing guides and fee schedules webpage (scroll down to Telehealth under Billing guides and fee schedules) for a complete list of audio-only telemedicine procedure codes.

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.

SOURCE: Medicaid Provider Guide, Telemedicine Policy and Billing, p. 21-22 (Apr. 2024). (Accessed Mar. 2024).

Audio-only telemedicine is the delivery of health care services using audio-only technology, permitting real-time communication between the client at the originating site and the provider, for the purposes of diagnosis, consultation, or treatment.

SOURCE: Medicaid Provider Guide, Telemedicine Policy and Billing, p. 7 (Apr. 2024). (Accessed Mar. 2024).

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

SOURCE: Medicaid Provider Guide, Telemedicine Policy and Billing, p. 21 (Apr. 2024). (Accessed Mar. 2024).

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 Mar. 2024).

For health care services provided by audio-only telemedicine, the provider and client must have an established relationship.

SOURCE: WAC 182-501-0300(3)(d). (Accessed Mar. 2024).

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 provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:

  • 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 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;

If a provider intends to bill a patient, a behavioral health administrative services organization, or a managed care organization 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.

SOURCE: Revised Code of Washington 74.09.325 as amended by SB 5821 (2024 Legislative Session)71.24.335. (Accessed Mar. 2024).

Managed Care

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

SOURCE: Revised Code of Washington 74.09.325. (Accessed Mar. 2024).

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.

A phone call between a provider and a parent when the student is not present is not billable. If the student is present and the provider is speaking with the parent while the parent assists the child with performing the activities as part of the service delivery, this is billable.

HCA does not cover the following services provided through telemedicine:

  • 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, SBHS Billing, p. 35-40 (Oct. 2023). (Accessed Mar. 2024).

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.

Medical abortion services provided via audio-only telemedicine are not eligible for the HCPCS code S0199 bundled payment.

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. 231-234 (Mar. 2024). (Accessed Mar. 2024).

Maternity Support Services and Infant Case Management

When billing for MSS- and ICM-covered services provided via telephone (audioonly) or telemedicine, use the appropriate MSS or ICM procedure code and place of service (POS) code. When billing for MSS or ICM services provided via audio-only telemedicine, you must include modifier 93 (synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system) on the claim. Modifier 93 indicates that the services were provided using an audio-only system. Claims for services provided via telemedicine do not require an additional modifier to indicate services were provided via HIPAA-compliant, real-time video and audio technology

SOURCE: WA State Health Care Authority. Medicaid Provider Guide. Maternity Support Services and Infant Case Management Billing, p. 46-47 (Oct. 2023). (Accessed Mar. 2024).

Physical Therapy, Occupational Therapy, and Speech Therapy Services

Audio-only telemedicine may require participation of a caregiver to assist with the treatment. Providers are responsible for making this determination and ensuring appropriate assistance or supervision, or both. Audio-only telemedicine for the evaluation of speech is:

  • Allowed for patients who have already had a face-to-face (in-person), initial evaluation with the provider.
  • Permitted for less than 50% of the visits per year.
  • Not allowed for outpatient physical or occupational therapy

SOURCE: WA State Health Care Authority, Neurodevelopmental Centers Billing Guide, p. 16 (Oct. 2023); WA State Health Care Authority, Outpatient Rehabilitation Billing Guide, p. 17 (Jan. 2024). (Accessed Mar. 2024).

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. 77 (Mar. 2024). (Accessed Mar. 2024).

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. 58 (Mar. 2024). (Accessed Mar. 2024).

Texting/Emailing/Virtual Check-Ins

During the federal PHE, HCA considered texting and emailing a virtual check-in and allowed physical and behavioral health providers to bill HCA for these check-ins using HCPCS code G2012. With the end of the federal PHE, effective May 12, 2023, virtual check-ins to include emailing and texting for physical and behavioral health services will no longer be covered. Note: HCA still covers HCPCS code G2012 for physical health providers, but this procedure code must not be billed for emailing or texting. HCPCS code G2012 is no longer allowable for behavioral health services.

SOURCE: WA State Health Care Authority, Medicaid Provider Alert, Apr. 27, 2023 – Correction, & Medicaid Provider Alert, Apr. 21, 2023 – Coverage of emailing and texting for Telehealth Services. (Accessed Mar. 2024).

Communication Technology-Based Procedure Codes

Evaluation and management services may be provided via telephone or patient portal to established patients. Virtual check-ins and e-consults are also covered in certain instances. See manual for eligible codes and requirements.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 26-27 (Apr. 2024). (Accessed Mar. 2024).

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. (Apr. 2024). (Accessed Mar. 2024).

Home Health and Hospice

“Audio-only telemedicine” means the delivery of health care services through the use of HIPAA-compliant audio-only technology (including web-based applications), permitting real-time communication between the patient and the agency provider for the purpose of consultation, education, diagnosis, or treatment, as appropriate per scope of practice. “Audio-only telemedicine” also includes supervision of home health aide services to evaluate compliance with the plan of care and patient satisfaction with care. “Audio-only telemedicine” does not include the use of facsimile, electronic mail, or text messages.

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

SOURCE: WAC 246-335-510 & WAC 246-335-610. (Accessed Mar. 2024).


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. 17 (Apr. 2024); WA State Health Care Authority, Medicaid Provider Guide, SBHS Billing, p. 39 (Oct 2023). (Accessed Mar. 2024).

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 Mar. 2024).

Last updated 03/28/2024

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. 18-19 (Apr. 2024). (Accessed Mar. 2024).

The medicaid agency determines the health care services that may be paid for when provided through telemedicine or store and forward technology as authorized by state law, including RCW 71.24.33574.09.325, and 74.09.327.  The agency’s designee, including an agency-contracted managed care entity (managed care organization (MCO) or behavioral health administrative services organization (BH-ASO)), pays providers for health care services delivered through telemedicine or store and forward technology in the same amount as when the health care services are provided in person, except as provided in these rules, RCW 71.24.335, and 74.09.325.

SOURCE: WAC 182-501-0300(3)(a) & 5(a). (Accessed Mar. 2024).

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 under subsection (1) of this section 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 Mar. 2024).

Behavioral Health Services

Upon initiation or renewal of a contract with the authority, behavioral health administrative services organizations and managed care organizations shall reimburse a provider for a behavioral health service provided to a covered person through telemedicine or store and forward technology if:
  • 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 Mar. 2024).

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. (Accessed Mar. 2024).


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 distinguish them from facility providers and ensure that they receive the nonfacility rate.

For licensed behavioral health agencies (BHA)—Using modifier 95 and distinguishing between facility/nonfacility are not applicable for behavioral health providers who use the following guides: – Service encounter reporting instructions (SERI) guide – Mental health billing guide (Part 2) – Substance use disorder (SUD) billing guide

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. 18-20 (Apr. 2024). (Accessed Mar. 2024).

Health care services that are authorized to be provided through telemedicine or store and forward technology are identified in the agency’s provider guides and fee schedules. The agency determines the health care services that may be provided through telemedicine or store and forward technology based on whether the health care service is:

  • A covered service when provided in person by the provider;
  • Medically necessary;
  • Determined to be safely and effectively provided through telemedicine or store and forward technology based on generally accepted health care practices and standards; and
  • Provided through a technology that meets the standards required by state and federal laws governing the privacy and security of protected health information.

SOURCE: WAC 182-501-0300(3)(d). (Accessed Mar. 2024).

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. For a school district to receive reimbursement for telemedicine, the provider furnishing services 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. School districts are reimbursed for services provided through telemedicine at the same rate as if the service was provided in person.

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. 35-38 (Oct. 2023). (Accessed Mar. 2024).

Applied Behavior Analysis (ABA)

Applied Behavior Analysis (ABA) services delivered using telemedicine may be reimbursed by HCA when billed in accordance with the rules regarding telemedicine and store-and-forward technology as outlined in WAC 182-501-0300 and HCA’s published billing instructions for ABA and telemedicine services.

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. 38 (Apr. 2024). (Accessed Mar. 2024).

Applied behavior analysis (ABA) services delivered using telemedicine may be reimbursed by the agency when billed in accordance with the rules regarding telemedicine and store-and-forward technology in WAC 182-501-0300 and the agency’s published billing instructions.

SOURCE: WAC 182-531A-1200. (Accessed Mar. 2024).

Effective for dates of service on and after October 1, 2023,some services provided as part of an early childhood intensive behavioral intervention day treatment program (CPT® code H2020) may occur via synchronous, audio-visual telemedicine. Speech and language pathology services must occur face-to-face, either in-person or via audio-visual telemedicine.

Additionally, a minimum of 2 caregiver training sessions must occur in-person and additional sessions may occur either in-person or via audio-visual telemedicine. Supervision of Certified Behavior Technicians (CBTs) may occur via audio-visual telemedicine; however, a Lead Behavior Analysis Therapist (LBAT) is required to be on-site for all hours the day treatment program is in session.

SOURCE: WA State Health Care Authority Provider Bulletin (Sept. 2023). (Accessed Mar. 2024).

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. 74-75. (Apr. 2024). (Accessed Mar. 2024).

Behavioral Health Services

To bill for outpatient behavioral health services via telemedicine, see the appropriate billing guidance to report the service modality/procedure code (CPT® or HCPC code) consistent with the instructions on the telemedicine page in the Service Encounter Reporting Instructions (SERI), or Part I or Part II of HCA’s Mental Health Services Billing Guide.

SOURCE: WA State Health Care Authority, Medicaid Behavioral Health Policy and Billing FAQ, p. 2. (Oct. 2023). (Accessed Mar. 2024).

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. 47. (Apr. 2024). (Accessed Mar. 2024).

Home Health Services

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

SOURCE: WA Admin Code 182-551-2040. (Accessed Mar. 2024).

Home Health and Hospice

Certain supervisory visits may be conducted on-site, via telemedicine, or via audio-only telemedicine and must be conducted by a licensed nurse or licensed therapist in accordance with the appropriate practice acts. A supervisory visit conducted via audio-only telemedicine is only permitted for patients that have an established relationship with the provider consistent with WAC 246-335-510(8). A supervisory visit conducted via telemedicine or via audio-only telemedicine may not be used to fulfill the annual performance evaluations and on-site observation of care and skills requirements in WAC 246-335-525(16).

SOURCE: WAC 246-335-545 & WAC 246-335-645. (Accessed Mar. 2024).

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. 77 (Mar. 2024). (Accessed Mar. 2024).

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. 234 (Mar. 2024). (Accessed Mar. 2024).

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. 202 (Mar. 2024). (Accessed Mar. 2024).

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. 230 (Mar. 2024). (Accessed Mar. 2024).

Maternal Support Services (MSS)

MSS clients may be eligible for telemedicine. Infant case management (ICM) clients and their parents may be eligible for telemedicine. 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. 9-10 (Oct. 2023). (Accessed Mar. 2024).

Physical Therapy, Occupational Therapy, and Speech Therapy Services

HCA pays for evaluation, re-evaluation, and treatment of some physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services when provided via audio-visual telemedicine. HCA pays for telehealth services for PT, OT, or ST when provided via audio-visual telemedicine and billed with specific procedure codes if clinically appropriate as determined by the practitioner, per standard of care. Services delivered by synchronous audio-visual technology may require participation of a caregiver to assist with the treatment. Providers are responsible for making this determination and ensuring there is appropriate assistance or supervision, or both.

SOURCE: WA State Health Care Authority, Neurodevelopmental Centers Billing Guide, p. 13 (Oct. 2023).; WA State Health Care Authority, Outpatient Rehabilitation Billing Guide, p. 15 (Jan. 2024). (Accessed Mar. 2024).

Federally Qualified Health Center (FQHC)

A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter eligible client and an FQHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Federally Qualified Health Centers, p. 9 (Apr. 2024). (Accessed Mar. 2024).

Rural Health Clinic (RHC)

A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter-eligible client and an RHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Rural Health Clinics, p. 8. (Apr. 2024). (Accessed Mar. 2024).


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. 48, (Apr. 2024); Federally Qualified Health Centers, p. 64-65. (Apr. 2024). (Accessed Mar. 2024).

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 nonlicensed 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 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. 35 (Oct. 2023). (Accessed Mar. 2024).

Tribal Health Program

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

SOURCE: WA State Health Care Authority, Tribal Health Billing Guide, p. 18 (Jan. 2024). (Accessed Mar. 2024).

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 Telemedicine Policy and Billing Guide, p. 18 (Apr. 2024). (Accessed Mar. 2024).


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 Telemedicine Policy and Billing Guide, p. 16-18 (Apr. 2024). (Accessed Mar. 2024).

Managed Care

The following are eligible originating sites.

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

SOURCE: RCW 74.09.325. (Accessed Mar. 2024).

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. 36-37 (Oct. 2023). (Accessed Mar. 2024).

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, Applied Behavior Analysis, p. 38 (Apr. 2024). (Accessed Mar. 2024).


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 Mar. 2024).

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).

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 17-18 (Apr. 2024),  WAC 182-501-0300(7)(a). (Accessed Mar. 2024).


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 setting

See manual for specific billing instructions for each.

SOURCE: WA State Health Care Authority. Medicaid Telemedicine Policy and Billing Guide, p. 17-18 (Apr. 2024) & WAC 182-501-0300(7). (Accessed Mar. 2024).

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. (Accessed Mar. 2024). 

Managed Care

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

  • Hospital;
  • Rural health clinic;
  • Federally qualified health center;
  • Physician’s or other health care provider’s office;
  • Licensed or certified behavioral health agency;
  • Skilled nursing facility;
  • Home or any location determined by the individual receiving the service; or
  • 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 Mar. 2024).

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. 48 (Apr. 2024) & Federally Qualified Health Centers, p. 64-65 (Apr. 2024). (Accessed Mar. 2024).

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. 39 (Oct. 2023). (Accessed Mar. 2024).

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. 234 (Mar. 2024). (Accessed Mar. 2024).

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. 20 (Jan. 2024). (Accessed Mar. 2024).

Last updated 03/29/2024

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 (e.g., electronic stethoscopes, mobile automatic blood pressure device, etc.) were used
  • The location of the client
  • The location of the provider. Include the following:
    • The state in which the service was provided for users of the following documents:
      • Part 2 (specialized) of HCA’s Mental Health Services Billing Guide
      • HCA’s Substance Use Disorder Billing Guide
      • HCA’s Service Encounter Reporting Instructions (SERI)
    • For all others, the state in which the provider was located at the time services were provided and for specific service locations (e.g., facility-based), whether the provider was in a facility at the time services were provided.
  • 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 or the duration of service when billing is based on time
  • 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. 16-17 (Apr. 2024). (Accessed Mar. 2024).

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 distinguish them from facility providers and ensure that they receive the nonfacility rate.

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. 19-20 (Apr. 2024). (Accessed Mar. 2024).

Health care services that are authorized to be provided through telemedicine or store and forward technology are identified in the agency’s provider guides and fee schedules.

To receive payment for an audio-only telemedicine service, a provider must obtain client consent before delivering the service to the client. The client’s consent to receive services via audio-only telemedicine must:

  • Acknowledge the provider will bill the agency or the agency’s designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization) for the service; and
  • Be documented in the client’s medical record.

A provider may only bill a client for services if they comply with the requirements in WAC 182-502-0160.

Providers using telemedicine or store and forward technology must document in the client’s medical record the:

  • Technology used to deliver the health care service by telemedicine or store and forward technology (audio, visual, or other means) and any assistive technologies used;
  • Client’s location for telemedicine only. This information is not required when a provider uses store and forward technology;
  • People attending the appointment with the client (e.g., family, friends, or caregivers) during the delivery of the health care service;
  • Provider’s location;
  • Names and credentials (MD, ARNP, RN, PA, CNA, LMHP, etc.) of all originating and distant site providers involved in the delivery of the health care service;
  • Start and end time or duration of service when billing is based on time;
  • Client’s consent for the billing of audio-only telemedicine services.

SOURCE: WAC 182-501-0300 (4)(a), (6)(a), & (8)(b). (Accessed Mar. 2024).

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. 38 (Apr. 2024). (Accessed Mar. 2024).

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. 35-37 (Oct. 2023). (Accessed Mar. 2024).

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. Explain that personal health information may be disclosed.
  • Ask clients if they need assistive devices to participate in virtual visits.
  • Include accessibility options (e.g., screen readers, closed captioning, etc.) within your telehealth programs.
  • Use technology designed with equity in mind when it comes to speech recognition.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide. Telemedicine Policy and Billing, p. 8. (Apr. 2024). (Accessed Mar. 2024).

Childbirth Education Classes

Agency-approved online classes are allowed with a one-on-one check-in with the client and qualified childbirth education provider during or after the online classes have been completed by the client. As part of the coverage requirements, the provider must follow up with clients participating in online classes through a telemedicine, including audio-only, visit or an in-person visit. If the client does not appear for the follow up visit, the provider must attempt to connect with the client one more time before billing the agency.

SOURCE: WAC 182-533-0390 as amended by Final Rule. (Accessed Mar. 2024).

Last updated 03/28/2024

Out of State Providers

You must be licensed according to Washington State law to bill for telemedicine or telehealth services. Service(s) must be rendered consistent with the scope of professional licensure or certification. See the Washington State Department of Health website for further information and details related to each option. This rule does not pertain to providers in a Direct IHS Clinic, Tribal Clinic, or Tribal FQHC as those providers may be licensed in any state per federal law. If the Washington Apple Health (Medicaid) client is receiving services outside of Washington State by a Washington State provider, the provider must follow the applicable laws of the state in which the client is located.

SOURCE: WA State Health Care Authority Behavioral Health Policy and Billing FAQ (Oct. 2023). (Accessed Mar. 2024).

A distant site must be located within the continental United States, Hawaii, District of Columbia, or any United States territory (e.g., Puerto Rico). A distant site is where a physician or other licensed provider, delivering a professional service, is physically located at the time the service is provided through telemedicine.

SOURCE: WA State Health Care Authority Telemedicine Policy and Billing Manual (Apr. 2024), p. 7, 18. (Accessed Mar. 2024).

Last updated 03/25/2024

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 (Apr. 2024) WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., RPM, p. 98 (Mar. 2024). (Accessed Mar. 2024).

Last updated 03/28/2024

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. 98-99 (Mar. 2024), WAC 182-551-2125(1). (Accessed Mar. 2024)

Home Health Services

The medicaid agency pays for one telemedicine interaction, per eligible client, per day, based on the ordering physician’s home health plan of care. To receive payment for the delivery of home health services through telemedicine, the services must involve:

(a) An assessment, problem identification, 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 includes assessment of response to previous changes in the plan of care; and
  • Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care; and

(b) Implementation of a management plan through one or more of the following:

  • Teaching regarding medication management, as appropriate;
  • Teaching 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 addition of other skilled services;
  • Coordination of care with the ordering physician regarding findings;
  • Coordination and referral to other medical providers as needed; and
  • Referral to the emergency room as needed.

The medicaid agency does not require prior authorization for the delivery of home health services through telemedicine. The medicaid agency does not pay for the purchase, rental, or repair of telemedicine equipment. Electronic visit verification requirements are not applicable to home health services delivered through telemedicine. Other program rules may apply similar or the same record requirements to providers of home health services.

SOURCE: WAC 182-551-2125. (Accessed Mar. 2024).

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. 27-28. (Oct. 2023). (Accessed Mar. 2024).


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. 98-99 (Mar. 2024). (Accessed Mar. 2024).

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 codes to bill.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 28. (Oct. 2023). (Accessed Mar. 2024).


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. 99 (Mar. 2024). (Accessed Mar. 2024).


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. 98-99 (Mar. 2024). (Accessed Mar. 2024).

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. 27-29. (Oct. 2023). (Accessed Mar. 2024).

Last updated 03/28/2024

Store and Forward

POLICY

The medicaid agency determines the health care services that may be paid for when provided through telemedicine or store and forward technology as authorized by state law, including RCW 71.24.33574.09.325, and 74.09.327.

SOURCE: WAC 182-501-0300(3)(a). (Accessed Mar. 2024).

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:

  • 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. 23 (Apr. 2024). (Accessed Mar. 2024).

“Store and forward technology” means use of an asynchronous transmission of a covered person’s medical or behavioral health information from an originating site to the health care provider at a distant site which results in medical or behavioral health 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. 7 (Apr. 2024). (Accessed Mar. 2024).

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 Mar. 2024).

Behavioral Health Administrative Services Organizations and Managed Care Organizations

Upon initiation or renewal of a contract with the authority, behavioral health administrative services organizations and managed care organizations shall reimburse a provider for a behavioral health service provided to a covered person through telemedicine or store and forward technology if:

  • 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.

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.

 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 Mar. 2024).


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. 345 (Mar. 2024). (Accessed Mar. 2024).

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. 24-25 (Apr. 2024). (Accessed Mar. 2024).

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. 81 (Mar. 2024). (Accessed Mar. 2024).

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. (Apr. 2024). (Accessed Mar. 2024).

Behavioral Health

For behavioral health services authorized for delivery through store and forward technology, there must be an associated visit between the referring provider and the client.

SOURCE: WAC 182-501-0300(3)(d). (Accessed Mar. 2024).

Communication Technology-Based Procedure Codes

Evaluation and management services may be provided via telephone or patient portal to established patients. Virtual check-ins and e-consults are also covered in certain instances. See manual for eligible codes and requirements.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 26-27 (Apr. 2024). (Accessed Mar. 2024).

 


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. 23 (Apr. 2024). (Accessed Mar. 2024).

Last updated 06/20/2024

Cross State Licensing

The legislature created a specific exemption to the licensure requirement for telemedicine practitioner-to-practitioner consultations. The consultation exemption permits a practitioner licensed in another state in which the practitioner resides to use telemedicine or other means to consult with a Washington licensed practitioner who remains responsible for diagnosing and treating the patient in Washington. The law does not require real time communication between practitioners.

Additionally, the WMC does not require a license when a patient seeks a second opinion or a consultation with a specialist out of state, such as a cancer center, and sends medical records to the specialist to review and provide input on treatment. In this case, the specialist in the distant state does not need a license to practice medicine in Washington to review the records and provide an opinion, but not treatment, regarding the patient’s care.

Another common situation that is not specifically addressed by a statutory exemption is when a patient with an established relationship with a practitioner licensed in another state crosses the border into Washington and requires medical care. In some cases, permitting the physician in the patient’s home state to provide temporary continuous care is in the patient’s best interest. So long as the out-of-state practitioner provides temporary continuity of care to the patient, the practitioner would not require a Washington license.

SOURCE: WA Medical Commission Updated Telemedicine Policy (July 2022). (Accessed Jun. 2024).

There is no prohibition against the consultation through telemedicine by a practitioner, licensed by another state or territory in which he or she resides, with a practitioner licensed in WA who has responsibility for the diagnosis and treatment of the patient within WA.

SOURCE: RCW 18.71.030(6) and RCW 18.57.040. (Accessed Jun. 2024).

Uniform Telehealth Act – Effective June 6, 2024

A health care practitioner may provide telehealth services to a patient located in this state if the services are consistent with the health care practitioner’s scope of practice in this state, applicable professional practice standards in this state, and requirements and limitations of federal law and law of this state.

This chapter does not authorize provision of health care otherwise regulated by federal law or law of this state, unless the provision of health care complies with the requirements, limitations, and prohibitions of the federal law or law of this state.

A practitioner-patient relationship may be established through telehealth. A practitioner-patient relationship may not be established through email, instant messaging, text messaging, or fax.

A health care practitioner who provides telehealth services to a patient located in this state shall provide the services in compliance with the professional practice standards applicable to a health care practitioner who provides comparable in-person health care in this state. Professional practice standards and law applicable to the provision of health care in this state, including standards and law relating to prescribing medication or treatment, identity verification, documentation, informed consent, confidentiality, privacy, and security, apply to the provision of telehealth services in this state.

A disciplining authority in this state shall not adopt or enforce a rule that establishes a different professional practice standard for telehealth services merely because the services are provided through telehealth or limits the telecommunication technology that may be used for telehealth services.

An out-of-state health care practitioner may provide telehealth services to a patient located in this state if the out-of-state health care practitioner:

  1. Holds a current license or certification required to provide health care in this state or is otherwise authorized to provide health care in this state, including through a multistate compact of which this state is a member; or
  2. Holds a license or certification in good standing in another state and provides the telehealth services:
    1. In the form of a consultation with a health care practitioner who has a practitioner-patient relationship with the patient and who remains responsible for diagnosing and treating the patient in the state
    2. In the form of a specialty assessment, diagnosis, or recommendation for treatment. This does not include the provision of treatment; or
    3. In the form of follow up by a primary care practitioner, mental health practitioner, or recognized clinical specialist to maintain continuity of care with an established patient who is temporarily located in this state and received treatment in the state where the practitioner is located and licensed.

The provision of a telehealth service under this chapter occurs at the patient’s location at the time the service is provided. In a civil action arising out of a health care practitioner’s provision of a telehealth service to a patient under this chapter, brought by the patient or the patient’s personal representative, conservator, guardian, or a person entitled to bring a claim under the state’s wrongful death statute, venue is proper in the patient’s county of residence in this state or in another county authorized by law.

Disciplining  authorities may adopt rules to administer, enforce, implement, or interpret this chapter. In applying and construing this chapter, a court shall consider the promotion of uniformity of the law among jurisdictions that enact the uniform telehealth act.

Nothing in this act shall be construed to require a health carrier as defined in RCW 48.43.005, a health plan offered under chapter 41.05 RCW, or medical assistance offered under chapter 74.09 RCW to reimburse for telehealth services that do not meet statutory requirements for reimbursement of telemedicine services.

This chapter does not permit a health care practitioner to bill a patient directly for a telehealth service that is not a permissible telemedicine service under chapter 48.43, 41.05, or 74.09 7 RCW without receiving patient consent to be billed prior to providing the telehealth service.

SOURCE: RCW New Chapter under Title 18, as added by SB 5481 (2024 Legislative Session). (Accessed Jun. 2024).

Last updated 06/20/2024

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.   ‘Telemedicine’ includes audio-only telemedicine, but does not include facsimile, or email.”

“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.

“Audio-only telemedicine” 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 70.41.020, (Accessed Jun. 2024).

“Telehealth” includes telemedicine and means the use of synchronous or asynchronous telecommunication technology by a practitioner to provide health care to a patient at a different  physical location than the practitioner. “Telehealth” does not include the use, in isolation, of email, instant messaging, text messaging, or fax.

“Telehealth services” means health care provided through telehealth.

“Telecommunication technology” means technology that supports communication through electronic means. The term is not limited to regulated technology or technology associated with a regulated industry.

SOURCE: RCW New Title 18 Chapter, as added by SB 5481 (2024 Legislative Session). (Accessed Jun. 2024).

Hospice and Home Health

“Telehealth” means a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technology. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services.

“Telemedicine” means the delivery of health care services through the use of HIPAA-compliant interactive audio and video technology, permitting real-time communication between the patient and the agency provider for the purpose of consultation, education, supervision, diagnosis, or treatment, as appropriate per scope of practice. “Telemedicine” also includes supervision of home health aide services to evaluate compliance with the plan of care and patient satisfaction with care. “Telemedicine” does not include the use of audio-only telephone, facsimile, electronic mail, or text messages.

SOURCE: WAC 246-335-610 (20) & (21).. WAC 246-335-510 (23) & (24). (Accessed Jun. 2024).

Audio-only telemedicine” means the delivery of health care services through the use of HIPAA-compliant audio-only technology (including web-based applications), permitting real-time communication between the patient and the agency provider for the purpose of consultation, education, diagnosis, or treatment, as appropriate per scope of practice. “Audio-only telemedicine” also includes supervision of home health aide services to evaluate compliance with the plan of care and patient satisfaction with care. “Audio-only telemedicine” does not include the use of facsimile, electronic mail, or text messages.

SOURCE: WAC 246-335-510 (3)WAC 246-335-610. (Accessed Jun. 2024).

Physical and Occupational Therapy

“Telehealth means providing physical therapy [or occupational therapy] via electronic communication where the physical [occupational] therapist or physical [or occupational] therapist assistant and the patient are not at the same physical location.”

SOURCE: WAC 246-915-187(3(a)) & 246-847-176.(1) (Accessed Jun. 2024).

Washington Medical Commission

Telemedicine as a mode of delivering healthcare services using telecommunications technologies by a practitioner to a patient or to consult with another health care provider at a different physical location than the practitioner. Telemedicine includes real-time interactive services, store-and-forward technologies, and remote monitoring.

Source: WA Medical Commission Updated Telehealth Policy (July 2022).  (Accessed Jun. 2024).

Last updated 03/30/2024

Licensure Compacts

Member of the Interstate Medical Licensure Compact.

SOURCE: The IMLC. (Accessed Mar. 2024).

Member of Physical Therapy Compact.

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

Enacted Occupational Therapy Licensure Compact.

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

Member of the Psychology Interjurisdictional Compact.

SOURCE: Psychology Interjurisdictional Compact. (Accessed Mar. 2024).

Enacted Counseling Compact.

SOURCE: Counseling Compact Map. HB 1069 (2023 Session). (Accessed Mar. 2024).

Enacted Audiology and Speech-Language Pathology Compact.

SOURCE: ASLP-IC Compact Map. HB 1001 (2023 Session). (Accessed Mar. 2024).

Enacted Social Work Licensure Compact.

SOURCE: SW Compact Map. HB 1939 (2024 Session). (Accessed Mar. 2024).

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

Last updated 03/30/2024

Miscellaneous

Beginning Jan. 1, 2021, a health care professional who provides clinical services through telemedicine, other than a physician licensed under chapter 18.71 RCW or an osteopathic physician licensed under chapter 18.57 RCW, shall complete a telemedicine training. By January 1, 2020, the telemedicine collaborative shall make a telemedicine training available on its web site for use by health care professionals who use telemedicine technology. If a health care professional completes the training, the health care professional shall sign and retain an attestation. The training:

  • Must include information on current state and federal law, liability, informed consent, and other criteria established by the collaborative for the advancement of telemedicine, in collaboration with the department and the Washington state medical quality assurance commission;
  • Must include a question and answer methodology to demonstrate accrual of knowledge; and
  • May be made available in electronic format and completed over the internet.

A health care professional is deemed to have met the requirements of subsection (2) of this section if the health care professional:

  • Completes an alternative telemedicine training; and
  • Signs and retains an attestation that he or she completed the alternative telemedicine training.

SOURCE: RCW 43.70.495 (WA SB 6061 – 2020). (Accessed Mar. 2024).

Collaborative for the advancement of telemedicine was created to develop recommendations on improving reimbursement and access to care, and review the concept of telemedicine payment parity.  They were required to submit policy reports with recommendations in December 2017, 2018, and December 2021.  Recent legislation requires the collaborative to study store and forward technology with an emphasis on utilization, whether it should be paid for at parity, the potential for store and forward to improve rural health outcomes and ocular services.

Effective June, 6, 2024, the statute has been updated by recent legislation to replace references to telemedicine to telehealth and additionally require the Collaborative to review the proposal authored by the uniform law commission for the state to implement a process for out-of-state health care providers to register with the disciplinary authority regulating their profession allowing that provider to provide services through telehealth or store and forward technology to persons located in this state. By December 1, 2024, the collaborative must submit a report to the legislature on its recommendations regarding the proposal.

SOURCE: RCW 28B.20.830 as amended by SB 5481 (2024 Legislation). (Accessed Mar. 2024).

The insurance commissioner, in collaboration with the Washington state telehealth collaborative and the health care authority, shall study and make recommendations for audio-only telemedicine, among other items.

SOURCE: HB 1196 (2021 Session), (Accessed Mar. 2024).

During a telemedicine visit, supervision over a medical assistant assisting a health care practitioner with the telemedicine visit may be provided through interactive audio and video telemedicine technology.

SOURCE: Revised Code of Washington Sec. 18.360.010 & WAC 246-827-0140 as added by Permanent Rule. (Accessed Mar. 2024).

When administering intramuscular injections for the purposes of treating a known or suspected syphilis infection in accordance with RCW 18.360.050, a medical assistant-certified or medical assistant-registered may be supervised through interactive audio or video telemedicine technology.

SOURCE: Revised Code of Washington Sec. 18.360.010 as amended by SB 5983 (2024 Legislative Session). (Accessed Mar. 2024).

Home Health and Hospice

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

SOURCE: WAC 246-335-510(8)WAC 246-335-610. (Accessed Mar. 2024).

For patients receiving acute care services, supervision of the home health aide services with or without the home health aide present must occur once a month to evaluate compliance with the plan of care and patient satisfaction with care. The supervisory visit may be conducted on-site, via telemedicine, or via audio-only telemedicine and must be conducted by a licensed nurse or therapist in accordance with the appropriate practice acts.

For patients receiving maintenance care or home health aide only services, supervision of the home health aide services with or without the home health aide present must occur every six months to evaluate compliance with the plan of care and patient satisfaction with care. The supervisory visit may be conducted on-site, via telemedicine, or via audio-only telemedicine and must be conducted by a licensed nurse or licensed therapist in accordance with the appropriate practice acts.

A supervisory visit conducted via audio-only telemedicine in subsection (7) or (8) of this section is only permitted for patients that have an established relationship with the provider consistent with WAC 246-335-510(8).

A supervisory visit conducted via telemedicine or via audio-only telemedicine in subsection (7) or (8) of this section may not be used to fulfill the annual performance evaluations and on-site observation of care and skills requirements in WAC 246-335-525(16).

SOURCE: WAC 246-335-545(7-10)WAC 246-335-645. (Accessed Mar. 2024).

Last updated 06/20/2024

Online Prescribing

The WA Medical Quality Assurance Commission has issued guidance on the use telemedicine.  Guidance does not have the force of law, but can be considered by the Commission to be the standard of practice in the state.

A practitioner who uses telemedicine must establish a valid practitioner-patient relationship with the person who receives telemedicine services. The relationship is established when the practitioner agrees to undertake diagnosis or treatment of the patient and the patient agrees that the practitioner will diagnose or treat the patient. A valid practitioner-patient relationship may be established through telemedicine if the standard of care does not require an initial in- person encounter.

Prior to providing treatment, including issuing prescriptions, a practitioner who uses telemedicine should interview the patient to collect the relevant medical history and perform a physical examination, when medically necessary, sufficient for the diagnosis and treatment of the patient. A practitioner may not delegate an appropriate history and physical examination to an unlicensed person or to a licensed individual for whom that function would be out of the scope of the license.

Once a practitioner has obtained a relevant medical history and performed a physical examination, it is within the practitioner’s judgment to determine whether it is medically necessary to obtain a history or perform a physical examination at subsequent encounters. The technology used in a telemedicine encounter must be sufficient to establish an informed diagnosis as though the medical interview and physical examination had been performed inperson by the practitioner. An on-line questionnaire does not constitute an acceptable medical interview for the provision of treatment, including issuance of prescriptions, by a practitioner. The standard of care requires direct interaction with a licensed practitioner.

SOURCE: Washington Medical Commission, Defining and Providing Guidance on Telemedicine Usage, p. 4 (November 19, 2021). (Accessed Jun. 2024).

For purposes of authorizing the medical use of marijuana, a physician must complete an in-person physical exam or a remote physical exam when certain conditions are met. Following an in-person physical examination to authorize the use of marijuana for medical purposes, the health care professional may determine and note in the patient’s medical record that subsequent physical examinations for the purposes of renewing an authorization may occur through the use of telemedicine technology if the health care professional determines that requiring the qualifying patient to attend a physical examination in person to renew an authorization would likely result in severe hardship to the qualifying patient because of the qualifying patient’s physical or emotional condition.

SOURCE: Revised Code Washington Sec. 69.51A.030. (Accessed Jun. 2024).

Uniform Telehealth Act – Effective June 6, 2024

A practitioner-patient relationship may be established through telehealth. A practitioner-patient relationship may not be established through email, instant messaging, text messaging, or fax.

SOURCE: RCW New Title 18 Chapter, as added by SB 5481 (2024 Legislative Session). (Accessed Jun. 2024).

Last updated 06/20/2024

Professional Boards Standards

Washington Medical Commission

SOURCE: Defining and providing guidance on Telemedicine usage & Updated Guidance on Telemedicine (July 2022). (Accessed Jun. 2024).

Physical Therapy Practice Board

SOURCE: WAC 246-915-187 (Accessed Jun. 2024).

Occupational Therapy Practice Board

SOURCE: WAC 246-847-176 (Accessed Jun. 2024).

Board of Optometry

SOURCE: Board of Optometry Appropriate Use of Telehealth (Dec. 2018). (Accessed Jun. 2024).

Examining Board of Psychology

SOURCE: Telepsychology Appropriate Use of Telemedicine (Jan. 2016). (Accessed Jun. 2024).

Nursing Care Quality Assurance Commission

SOURCE: Telehealth Advanced Practice Nursing Care Services (Mar. 2021). (Accessed Jun. 2024).

Board of Hearing and Speech

SOURCE: Telepractice (Nov. 2018). (Accessed Jun. 2024).

Board of Naturopathy Guideline

SOURCE: Appropriate Use of Telemedicine (Nov. 2017). (Accessed Jun. 2024).

Uniform Telehealth Act – Effective June 6, 2024

A health care practitioner may provide telehealth services to a patient located in this state if the services are consistent with the health care practitioner’s scope of practice in this state, applicable professional practice standards in this state, and requirements and limitations of federal law and law of this state.

This chapter does not authorize provision of health care otherwise regulated by federal law or law of this state, unless the provision of health care complies with the requirements, limitations, and prohibitions of the federal law or law of this state.

A health care practitioner who provides telehealth services to a patient located in this state shall provide the services in compliance with the professional practice standards applicable to a health care practitioner who provides comparable in-person health care in this state. Professional practice standards and law applicable to the provision of health care in this state, including standards and law relating to prescribing medication or treatment, identity verification, documentation, informed consent, confidentiality, privacy, and security, apply to the provision of telehealth services in this state.

A disciplining authority in this state shall not adopt or enforce a rule that establishes a different professional practice standard for telehealth services merely because the services are provided through telehealth or limits the telecommunication technology that may be used for telehealth services.

SOURCE: RCW New Title 18 Chapter, as added by SB 5481 (2024 Legislative Session). (Accessed Jun. 2024).

Last updated 03/29/2024

Definition of Visit

“Encounter” – A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter-eligible client and an FQHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

SOURCE: WA Admin Code 182-548-1100. (Accessed Mar. 2024).

Encounter: A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter eligible client and an FQHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

All services must be documented in the client’s file to qualify for an encounter.

SOURCE: WA HCA Provider Guide, Federally Qualified Health Centers, p. 9, 21 (Apr. 2024). (Accessed Mar. 2024).

Last updated 03/29/2024

Eligible Distant Site

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: Federally Qualified Health Centers, p. 65. (Apr. 2024). (Accessed Mar. 2024).

Last updated 03/29/2024

Eligible Originating Site

FQHCs are authorized to serve as an originating site for telemedicine services.

SOURCE: WAC 182-531-1730.(3); WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 18 (Apr. 2024); Federally Qualified Health Centers, p. 64. (Apr. 2024). (Accessed Mar. 2024).

Last updated 03/29/2024

Facility Fee

FQHCs 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: Federally Qualified Health Centers, p. 64-65 (Apr. 2024). (Accessed Mar. 2024).

FQHCs are explicitly listed as an eligible originating site for the facility fee.

SOURCE: RCW 74.09.325; WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 18 (Apr. 2024). (Accessed Mar. 2024).

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. HCA does not pay an originating site facility fee to the client in any setting. Additionally, HCA does not pay an originating site facility fee in the following situations:

  • Audio-only telemedicine
  • Store and forward
  • If the originating site is:
    • The client’s home
    • A hospital (inpatient services)
    • A skilled nursing facility o Any location receiving payment for the client’s room and board
    • The same entity as the distant site or if the provider is employed by the same entity as the distant site

FQHCs are instructed to bill for the fee using HCPCS code Q3014.

SOURCE: WA State Health Care Authority. Medicaid Provider Guide, Telemedicine Policy and Billing, p. 17-18 (Apr. 2024). (Accessed Mar. 2024).

Last updated 03/29/2024

Home Eligible

Encounter locations – An encounter may take place in the health center or at other locations (such as mobile vans, clients’ homes, and extended care facilities) in which project-supported activities are carried out.

Services outside the FQHC – A service that is considered an encounter when performed in the FQHC is considered an encounter when performed outside the FQHC (e.g., in a nursing facility or in the client’s home) and is payable to the FQHC. A service not considered an encounter when performed inside the FQHC is also not considered an encounter when performed outside the FQHC, regardless of the place of service.

SOURCE: WA HCA Provider Guide, Federally Qualified Health Centers, p. 24 (Apr. 2024). (Accessed Mar. 2024).

FQHC core services include those professional services provided in the office, other medical facility, the patient’s place of residence (including nursing homes), or elsewhere, but not the institutional costs of the hospital, nursing facility, etc. Core services are covered for Medicaid patients.

SOURCE: WA HCA Provider Guide, Federally Qualified Health Centers, p. 46 (Apr. 2024). (Accessed Mar. 2024).

Last updated 03/29/2024

Modalities Allowed

Live Video

A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter eligible client and an FQHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

SOURCE: Federally Qualified Health Centers, p. 8 (Apr. 2024). (Accessed Mar. 2024).

See: WA Medicaid Live Video


Store and Forward

No explicit reference for FQHCs found.

See: WA Medicaid Store-and-Forward


Remote Patient Monitoring

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

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 99 (Mar. 2024). (Accessed Mar. 2024).

See: WA Medicaid RPM


Audio-Only

“Encounter” – A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter-eligible client and an FQHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

SOURCE: WA Admin Code 182-548-1100, (Accessed Mar. 2024).

Effective August 1, 2022, HCA pays for audio-only telemedicine services for specific procedure codes when provided and billed as directed in HCA provider billing guides. HCA published the list of audio-only codes on HCA’s Provider billing guides and fee schedules webpage. FQHCs may receive the encounter rate when billing as an audio-only code if the service being billed is encounter eligible and meets the billing requirements as outlined in the Encounters section of the FQHC guide.

SOURCE: Federally Qualified Health Centers, p. 65 (Apr. 2024). (Accessed Mar. 2024).

See: WA Medicaid Email, Phone, & Fax

Last updated 03/29/2024

Patient-Provider Relationship

No Reference Found

Last updated 03/29/2024

PPS Rate

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.

Effective August 1, 2022, HCA pays for audio-only telemedicine services for specific procedure codes when provided and billed as directed in HCA provider billing guides. FQHCs may receive the encounter rate when billing as an audio-only code if the service being billed is encounter eligible and meets the billing requirements as outlined in the Encounters section in the FQHC Guide.

SOURCE: Federally Qualified Health Centers, p. 65. (Oct. 2023). (Accessed Mar. 2024).

Encounter rate: A cost-based, facility-specific rate for covered FQHC services .

SOURCE: WA HCA Provider Guide, Federally Qualified Health Centers, p. 9 (Oct. 2023). (Accessed Mar. 2024).

The agency or the agency’s designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization) pays for encounter-eligible health care services authorized for delivery through telemedicine at the encounter rate when provided by:

  • Rural health clinics;
  • Federally qualified health centers; or
  • Direct Indian health service clinics, tribal clinics, or tribal federally qualified health centers.

SOURCE: WAC 182-501-0300(5)(b). (Accessed Mar. 2024).

Last updated 03/29/2024

Same Day Encounters

HCA limits encounters to one per client, per day, except in the following circumstances:
  • There is a subsequent visit in the same cost center (e.g., medical, dental, SUD, etc.) that requires separate evaluation and treatment on the same day for unrelated diagnoses; or
  • There are separate visits in different types of cost centers that occur with different health care professionals. (For example, a client with a separate medical and dental visit on the same day.)

All services provided within the same cost center, performed on the same day, must be included in the same encounter, except in the circumstances outlined above.

All FQHC services and supplies incidental to the provider’s services are included in the encounter rate payment.

FQHCs must provide services in a single encounter that are typically rendered in a single visit based on clinical guidance and standards of care.

Each encounter must be billed on a separate claim form. On each claim, to indicate that it is a separate encounter, enter “unrelated diagnosis,” the time of both visits in the Claim Note section, and the appropriate modifier for the service provided.

When billing two different claims for the same date of service, a modifier must be entered on at least one of the claims. The same modifier cannot be used on the first and second claim. HCA must fully process the first claim before the provider submits the second.

Documentation for all encounters must be kept in the client’s file.

Maternity Support Services (MSS)

HCA allows more than one Maternity Support Services (MSS) encounter, per day, per client, if they are:

  • Different types of services
  • Performed by different practitioners with different specialties
  • Billed on separate claim forms

When billing for more than one MSS encounter for the same date of service and client, use modifier XP with the HCPCS procedure code T1015 on the second claim.

Dental Services

Only one encounter per day at a dental clinic is covered. Exception: When a dental service requires multiple visits (e.g., root canals, crowns, dentures), an encounter code must be billed with the number of visits when the dental services are complete.

SOURCE: WA HCA Provider Guide, Federally Qualified Health Centers, p.  21, 30-32, 65 (Apr. 2024). (Accessed Mar. 2024).