Last updated 11/21/2022
Consent Requirements
On at least an annual basis, providers should supply and document that:
- The member expressed an understanding of their right to decline services provided via telehealth.
- Providers should develop and implement their own methods of informed consent to verify that a member agrees to receive services via telehealth.
- These methods must comply with all federal and state regulations and guidelines.
- Providers have flexibility in determining the most appropriate method to capture member consent for telehealth services. Examples of allowable methods include educating the member and obtaining verbal consent prior to the start of treatment or telehealth consent and privacy considerations as part of the notice of privacy practices. Refer to Wis. Admin. Code § DHS 94.03(2m) for additional guidance.
The following documentation requirements apply for e-consults:
- Verbal consent for each consultation must be documented in the member’s medical record. The member’s consent must include assurance that the member is aware of any applicable cost-sharing.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth &ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Last updated 11/21/2022
Definitions
Telehealth enables a provider who is located at a distant site to render the service remotely to a member located at an originating site using a combination of interactive video, audio, and externally acquired images through a networking environment.
“Telehealth” means the use of telecommunications technology by a Medicaid-enrolled provider to deliver functionally equivalent health care services including: assessment, diagnosis, consultation, treatment, and transfer of medically relevant data. Telehealth may include real-time interactive audio-only communication. Telehealth does not include communication between a certified provider and a member that consists solely of an email, text, or fax transmission.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Nov. 2022).
“Telehealth” means a practice of health care delivery, diagnosis, consultation, treatment, or transfer of medically relevant data by means of audio, video, or data communications that are used either during a patient visit or a consultation or are used to transfer medically relevant data about a patient. “Telehealth” does not include communications delivered solely by audio-only telephone, facsimile machine, or electronic mail unless the department specifies otherwise by rule.
“Asynchronous telehealth service” is telehealth that is used to transmit medical data about a patient to a provider when the transmission is not a 2-way, real-time, interactive communication.
“Interactive telehealth” means telehealth delivered using multimedia communication technology that permits 2-way, real-time, interactive communications between a certified provider of Medical Assistance at a distant site and the Medical Assistance recipient or the recipient’s provider.
SOURCE: WI Statute Sec. 49.45 (61). (Accessed Nov. 2022).
“Telehealth” means the use of telecommunications technology by a Medicaid-enrolled provider to deliver health care services including assessment, diagnosis, consultation, treatment, and transfer of medically relevant data in a functionally equivalent manner as that of an in-person contact. Telehealth may include real-time interactive audio-only communication. Telehealth does not include communication between a certified provider and a member that consists solely of an email, text, or fax transmission.
SOURCE: ForwardHealth Update Dec. 2021, No. 2021-50. (Accessed Nov. 2022).
“Telehealth” means the use of telecommunications technology by a Medicaid-enrolled provider to deliver health care services including assessment, diagnosis, consultation, treatment, or transfer of medically relevant data in a functionally equivalent manner as that of an in-person contact:
- Telehealth may include real-time interactive audio-only communication.
- Telehealth does not include communication between a certified provider and a member (for example, a child) that consists solely of an email, text,or fax transmission.
- School documentation may use a different term to represent telehealth such as, but not limited to, teleservice, virtual learning platform, or virtual services. ForwardHealth will accept the Individual Education Program (IEP) team’s chosen term for telehealth used in documentation.
SOURCE: ForwardHealth Update, No. 2022-02, January 2022. (Accessed Nov. 2022).
Last updated 11/21/2022
Email, Phone & Fax
The Department may promulgate rules specifying any telehealth service that is provided solely by audio-only telephone, facsimile machine or electronic mail as reimbursable under Medical Assistance.
SOURCE: WI Statute Sec. 49.45 (61). (Accessed Nov. 2022).
School-Based Services
The FQ or 93 modifiers should be used for any service performed via audio-only telehealth. The GT modifier should only be used to indicate services that were performed using audio-visual technology.
When possible, telehealth services should include both an audio and visual component. In circumstances where audio-visual telehealth is not possible due to member preference or technology limitations, telehealth may include real- time interactive audio-only communication if the provider feels the service is functionally equivalent to the in-person service and there are no face-to-face or in-person restrictions listed in the procedural definition of the service.
Documentation should include that the service was provided via interactive synchronous audio-only telehealth.
SOURCE: ForwardHealth Update, No. 2022-02, January 2022. (Accessed Nov. 2022).
When possible, telehealth services should include both an audio and visual component. In circumstances where audio-visual telehealth is not possible due to member preference or technology limitations, telehealth may include real-time interactive audio-only communication if the provider feels the service is functionally equivalent to the in-person service and there are no face-to-face or in-person restrictions listed in the procedural definition of the service.
Documentation should include that the service was provided via interactive synchronous audio-only telehealth.
Modifier 93 should be used for any service performed via audio-only telehealth. Modifier 93 is effective for dates of service on and after January 1, 2022.
Behavioral Health Services
Effective January 1, 2022, the FQ modifier should be used for audio-only behavioral health services and modifier FR should be used for behavioral health services where the supervising provider is present through audio-visual means and the patient and supervised provider are in-person.
For instances where the patient, supervising/billing provider, and supervised/ rendering provider are all interacting through audio-visual means, providers should use modifier 95 GT.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth & ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Teledentistry
Modifier 93 should be used for any service performed via audio-only telehealth. The GT modifier should only be used to indicate services performed using audio-visual technology.
When possible, telehealth services should include both an audio and visual component. In circumstances where audio-visual telehealth is not possible due to member preference or technology limitations, telehealth may include real-time interactive audio-only communication if the provider feels the service is functionally equivalent to the in-person service and there are no face-to-face or in-person restrictions listed in the procedural definition of the service.
Documentation should include that the service was provided via interactive synchronous audio-only telehealth.
SOURCE: ForwardHealth Update, Jan. 2022, No. 2022-01. (Accessed Nov. 2022).
Interprofessional Consultations (E-Consults)
An interprofessional consultation or e-consult is an assessment and management service in which a member’s treating provider requests the opinion and/or treatment advice of a provider with specific expertise (the consultant) to assist the treating provider in the diagnosis and/or management of the member’s condition without requiring the member to have face-to-face contact with the consultant. Both the treating and consulting providers may be reimbursed for the e-consult as described below.
Policy Requirements and Limitations
Consulting Providers
Consulting providers must be physicians enrolled in Wisconsin Medicaid as an eligible rendering provider. Consulting providers may bill CPT procedure codes 99446–99449 and 99451 under the following limitations:
- Services are not covered if the consultation leads to a transfer of care orother face-to-face service within the next 14 days or next available date of the consultant. Additionally, if the sole purpose of the consultation is to arrange a transfer of care or other face-to-face service, these procedure codes should not be submitted.
- Consulting services are covered once in a seven-day period.
Treating Providers
Treating providers may be a physician, nurse practitioner, physician assistant, or podiatrist enrolled in Wisconsin Medicaid as an eligible rendering provider. Treating providers may bill CPT procedure code 99452 as a covered service once in a 14-day period.
Both the consulting and treating providers must be enrolled in Wisconsin Medicaid to receive reimbursement for the e-consult and the consultation must be medically necessary.
Providers are expected to follow CPT guidelines including that the CPT procedure codes should not be submitted if the consulting provider saw the member in a face-to-face encounter within the previous 14 days.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth & ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Last updated 11/21/2022
Live Video
POLICY
The department shall provide reimbursement under the Medical Assistance program for any benefit that is a covered benefit under s. 49.46 (2) and that is delivered by a certified provider for Medical Assistance through interactive telehealth.
SOURCE: WI Statute 49.45(61), (Accessed Nov. 2022).
Only synchronous (two-way, real-time, interactive communications) services identified under permanent policy may be reimbursed when provided via telehealth (also known as “telemedicine”). ForwardHealth will require providers to follow permanent billing guidelines for synchronous telehealth services.
ForwardHealth reimburses the service rendered by distant site providers at the same rate as when the service is provided face-to-face.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022).
Only synchronous (two-way, real-time, interactive communications) and remote physiological monitoring services identified under permanent policy may be reimbursed when provided via telehealth effective on the first day of the first month after the federal public health emergency related to the COVID-19 pandemic expires. For example, if the public health emergency ends on April 12, 2022, permanent policy would become effective for dates of service on and after May 1, 2022. Temporary telehealth policy will remain in effect until the switch to permanent policy occurs when ForwardHealth will require providers
to follow permanent billing guidelines for synchronous telehealth and remote physiological monitoring services. Telehealth-related updates
to the ForwardHealth Online Handbook will be available following the implementation of permanent policy.
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
ELIGIBLE SERVICES/SPECIALTIES
On July 1, 2021, the fee schedule was updated to allow providers to identify services allowable under permanent telehealth policy. Procedure codes for services allowed under permanent telehealth policy have place of service (POS) code 02 (Telehealth) listed as an allowable POS.
Effective January 1, 2022, if POS code 02 is not listed as an allowable POS for a procedure code, the service will not be reimbursed under permanent telehealth policy.
SOURCE: ForwardHealth Update 2021-21, Jul. 1, 2021, (Accessed Nov. 2022).
Providers should refer to the Max Fee Schedules page for a complete list of services allowed under permanent telehealth policy. Effective for dates of service on and after April 1, 2022, procedure codes for services allowed under permanent telehealth policy have POS codes 02 and 10 listed as an allowable POS in the fee schedule. Complete descriptions are as follows:
- POS code 02: Telehealth Provided Other Than in Patient’s Home–The location where health services and health related services are provided or received through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
- POS code 10: Telehealth Provided in Patient’s Home–The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.
Claims for telehealth services must include all modifiers required by coverage policy, in addition to POS code 02 or 10 and the GT, FQ, or 93 modifier, in order to reimburse the claim correctly.
County-administered programs, school-based services, and any other programs that utilize cost reporting must include required modifiers, such as renderer credentials and group versus individual services, as well as correct details for cost reporting to ensure correct reimbursement.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022).
Statute requires reimbursement for any benefit that delivered via interactive telehealth that is a covered benefit under Medicaid.
Reimbursement must be provided for a consultation pertaining to a Medicaid recipient conducted through interactive telehealth between a certified provider of Medical Assistance and the recipient’s treating provider that is certified under medical assistance, except as provided by the Department by Rule.
Except as provided by the department by rule, Medicaid must cover all Medicare covered services. However, the Department may not cover or provide reimbursement for services that are first covered under the Medicare program after July 1, 2019 until the date that is one year after the date the service is covered under the Medicare program or the date the secretary explicitly approves the service as a Medical Assistance covered service, whichever is earlier.
The Department shall provide reimbursement under the Medical Assistance program for the following: Except as provided by the department by rule, services that are covered under the Medicare program under 42 USC 1395 et seq. for which the federal department of health and human services provides Medical Assistance federal financial participation and that are any of the following:
- Telehealth services;
- Remote physiologic monitoring,
- Remote evaluation of prerecorded patient information,
- Brief communication technology-based services,
- Care management services delivered through telehealth;
- Any other telehealth or communication technology-based services.
Any service not specified can be eligible if specified by the Department. The Department is required to promulgate rules specifying any services that are reimbursable. They may also exclude services from reimbursement.
SOURCE: WI Statute Sec. 49.45 (61). (Accessed Nov. 2022).
The following requirements apply to the use of telehealth:
- Both the member and the provider of the health care service must agree in order for a service to be performed via telehealth. If either the member or provider decline the use of telehealth for any reason, the service should be performed in-person.
- The member retains the option to refuse the delivery of health care services via telehealth at any time without affecting their right to future care or treatment and without risking the loss or withdrawal of any program benefits to which they would otherwise be entitled.
- Medicaid-enrolled providers must be able and willing to refer members to another provider if necessary, such as when telehealth services are not appropriate or cannot be functionally equivalent or if the member declines a telehealth visit.
- Title VI of the Civil Rights Act of 1964 requires recipients of federal financial assistance to take reasonable steps to make their programs, services, and activities accessible by eligible persons with limited English proficiency.
- The Americans with Disabilities Act requires that health care entities provide full and equal access for people with disabilities.
Providers should refer to the maximum allowable fee schedule for a complete list of services allowed under permanent telehealth policy. Procedure codes for services allowed under permanent telehealth policy have place of service (POS) codes 02 and 10 listed as an allowable POS in the fee schedule. Refer to the Telehealth topic (#510) for general claim submission requirements.
Certain types of benefits or services that are not appropriately delivered via telehealth include:
- Services that are not covered when provided in-person.
- Services that do not meet applicable laws, regulations, licensure requirements, or procedure code definitions if delivered via telehealth.
- Services where a provider is required to physically touch or examine the recipient and delegation is not appropriate.
- Services the provider declines to deliver via telehealth.
- Services the recipient declines to receive via telehealth.
- Transportation services.
- Services provided by personal care workers, home health aides, private duty nurses, or school-based service care attendants.
The health care provider at the distant site must determine the following:
- The service delivered via telehealth meets the procedural definition and components of the CPT or HCPCS procedure code, as defined by the American Medical Association, or the Current Dental Terminology procedure code, as defined by the American Dental Association.
- The service is functionally equivalent to an in-person service for the individual member and circumstances. Reimbursement is not available for services that cannot be provided via telehealth due to technical or equipment limitations.
Additional privacy considerations apply to members participating in group treatment via telehealth.
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Telestroke Services
ForwardHealth allows providers to be reimbursed for telestroke services. Telestroke services typically consist of the member and emergency providers at an originating site consulting with a specialist located at a distant site.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022).
School-Based Services
Allowable Services Via Telehealth Under School-Based Services: ForwardHealth will reimburse assessments, individual services, and group services delivered by telehealth when the service is documented in the child’s IEP as an identified service and the mode of delivery is clearly described in documentation as telehealth (using the IEP team’s chosen term for telehealth delivery) and all other coverage requirements are met for the following services:
- Audiology
- Counseling service
- Nursing
- Occupational therapy
- Physical therapy
- Psychological service
- Social work service
- Speech and language therapy
The following services do not meet the definition of functionally equivalent and are not covered as a telehealth service:
- Attendant care
- Transportation
SOURCE: ForwardHealth Update, No. 2022-02, January 2022. (Accessed Nov. 2022).
Teledentistry
The use of teledentistry services should be evaluated on an individual basis based on the member’s individual situation and will not be required by ForwardHealth. Providers should report code D9995 along with the applicable allowable oral evaluation procedure codes to indicate the service was delivered via synchronous teledentistry.
All telehealth services must follow the guidelines for functional equivalency.
“Functionally equivalent” means that when a service is provided via telehealth, the transmission of information must be of sufficient quality as to be the
same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable.
SOURCE: ForwardHealth Update No. 2022-01, Jan. 2022, (Accessed Nov. 2022).
Behavioral Health Services
The FQ modifier should be used for audio-only behavioral health services. The FR modifier should be used for behavioral health services where the supervising provider is present through audio-visual means and the patient and supervised provider are in-person.
For instances where the patient, supervising/billing provider, and supervised/ rendering provider are all interacting through audio-visual means, providers should use modifier GT.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022).
ELIGIBLE PROVIDERS
There is no restriction on the location of a distant site provider. In addition, there are no limitations on what provider types may be reimbursed for telehealth services.
Ancillary Providers
Claims for services provided via telehealth by distant site ancillary providers should continue to be submitted under the supervising physician’s NPI using the lowest appropriate level office or outpatient visit procedure code or other appropriate CPT code for the service performed. These services must be provided under the direct on-site supervision of a physician who is located at the same physical site as the ancillary provider and must be documented in the same manner as services that are provided face to face.
Pediatric and Health Professional Shortage Area-Eligible Services
Claims for services provided via telehealth by distant site providers may additionally qualify for pediatric (services for members 18 years of age and under) or HPSA-enhanced reimbursement. Pediatric and HPSA-eligible providers are required to indicate POS code 02 or 10, along with modifier GT, FQ, or 93 and the applicable pediatric or HPSA modifier, when submitting claims that qualify for enhanced reimbursement.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022)
Ancillary providers have specific requirements when providing care via telehealth. These providers are health care professionals that are not enrolled in Wisconsin Medicaid, such as staff nurses, dietician counselors, nutritionists, health educators, genetic counselors, and some nurse practitioners who practice under the direct supervision of a physician and bill under the supervising physician’s National Provider Identifier. (Nurse practitioners, nurse midwives, and anesthetists who are Medicaid-enrolled should refer to their service-specific area of the Online Handbook for billing information.)
See bulletin for additional supervision requirements.
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Birth to 3 Program
ForwardHealth will reimburse therapy providers supplying services as part of the Birth to 3 Program at an enhanced rate when occupational therapy, physical therapy, and/or speech therapy is performed using telehealth and the member is located in their natural environment.
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
FQHCs and RHCs
For the purpose of this Online Handbook topic, FQHC refers to Tribal and Out-of-State FQHCs. This topic does not apply to Community Health Centers subject to PPS reimbursement.
They may serve as originating site and distant site providers for telehealth services. See manual for details.
FQHCs and RHCs may report services provided via telehealth on the cost settlement report when the FQHC or RHC served as the distant site and the member is an established patient of the tribal FQHC or RHC at the time of the telehealth service.
Services billed with modifier GT, FQ, or 93 will be considered under the PPS reimbursement method for non-tribal FQHCs. Billing HCPCS procedure code T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS rate for fee-for-service encounters.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022).
The following are clarifications for federally qualified health centers:
- For currently covered services, services that are considered direct when provided in-person will be considered direct when provided via telehealth.
- Although federally qualified health centers are not directly reimbursed an originating site fee, HCPCS procedure code Q3014 should be billed for tracking purposes and for consideration in any potential future changes in scope.
- Fee-for-service claims must include HCPCS procedure code T1015 (Clinic visit/encounter, all-inclusive) when services are provided via telehealth in order for proper reimbursement.
- Refer to the Federally Qualified Health Centers and Rural Health Clinics section of the Telehealth topic (#510) for additional guidance.
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Community Health Centers
Services billed with modifier GT, FQ, or 93 will be considered under the PPS reimbursement. Billing HCPCS procedure codes T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS for an allowable encounter.
SOURCE: Telehealth for Community Health Centers (Accessed Nov. 2022).
Telestroke Services
ForwardHealth allows providers to be reimbursed for telestroke services. Telestroke services typically consist of the member and emergency providers at an originating site consulting with a specialist located at a distant site.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022).
School-Based Services
Supervision of Certified Occupational Therapy and Physical Therapy Assistants
ForwardHealth accepts supervision of certified occupational therapy assistants and physical therapist assistants in schools conducted via audio-visual telehealth.
Refer to the Delegation of Physical Therapy Services topic (#1463) and the Delegation of Occupational Therapy Services topic (#1464) of the ForwardHealth Online Handbook for additional information.
SOURCE: ForwardHealth Update, No. 2022-02, January 2022. &WI ForwardHealthOnline Handbook. Topic #1463 and #1464. (Accessed Nov. 2022).
ForwardHealth confirms that occupational therapy, physical therapy, and speech and language therapy services rendered through telehealth may be reimbursed when a parent or caregiver is needed to assist the child during the therapy session. As a reminder, ForwardHealth only reimburses for services when the child is present.
SOURCE: ForwardHealth Update, No. 2022-02, January 2022. (Accessed Nov. 2022).
Teledentistry
To maintain functional equivalency, a facilitator may be needed to assist with the teledentistry visit. Facilitators may include dental hygienists and other appropriately trained medical or dental professionals within their scope of practice. Facilitators are allowed for teledentistry when appropriate but are not separately reimbursed.
Dental hygienists can perform and bill for an assessment (D0191) of a member via teledentistry if the service is delivered with functional equivalency and the dental hygienist is individually enrolled in Wisconsin Medicaid.
SOURCE: ForwardHealth Update No. 2022-01, Jan. 2022, (Accessed Nov. 2022).
ELIGIBLE SITES
ForwardHealth allows coverage of telehealth for any originating site. However, only the following originating sites are eligible for a facility fee reimbursement:
- Hospitals, including emergency departments
- Office/clinic
- Skilled nursing facility
The following entities are also listed as allowable originating sites specifically:
- Federally Qualified Health Centers (FQHC)
- Rural Health Clinics (RHC)
FQHCs and RHCs
For the purpose of this Online Handbook topic, FQHC refers to Tribal and Out-of-State FQHCs. This topic does not apply to Community Health Centers subject to PPS reimbursement.
FQHCs and RHCs may serve as originating site and distant site providers for telehealth services.
The originating site facility fee is not a FQHC or RHC reportable encounter on the cost report. Any reimbursement for the originating site facility fee must be reported as a deductive value on the cost report.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth, (Accessed Nov. 2022).
Community Health Centers
ForwardHealth will not separately reimburse the CHC for originating site services because all costs for providing originating site services have already been incorporated into the PPS rates for CHCs. However, claims billed by CHCs for originating site services may be used for future rate setting purposes, and CHC costs associated with telehealth services may be reported for change in scope adjustment consideration.
SOURCE: Telehealth for Community Health Centers (Accessed Nov. 2022).
The department may not limit coverage or reimbursement of a service provided under par. (b) or (c) based on the location of the Medical Assistance recipient when the service is provided.
SOURCE: WI Statute Sec. 49.45 (61). (Accessed Nov. 2022).
Telestroke Services
ForwardHealth allows providers to be reimbursed for telestroke services. Telestroke services typically consist of the member and emergency providers at an originating site consulting with a specialist located at a distant site.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022).
The originating site is where the member is located during a telehealth visit. Only the provider at the originating site can bill for an originating site fee for hosting the member. The originating site should not use telehealth modifiers on the claims since all services are provided in-person.
- Office or clinic:
- Medical
- Dental
- Therapies (physical therapy, occupational therapy, speech andlanguage pathology)
- Behavioral and mental health agencies
- Hospital
- Skilled nursing facility
- Community mental health center
- Intermediate care facility for individuals with intellectual disabilities
- Pharmacy
- Day treatment facility
- Residential substance use disorder treatment facility
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth & ForwardHealth Update No. 2022-13, Mar. 2022. (Accessed Nov. 2022).
Procedure codes for services allowed under permanent telehealth policy have place of service (POS) codes 02 and 10 listed as an allowable POS in the fee schedule. To align with guidance from the Centers for Medicare & Medicaid Services, effective for dates of service on and after April 1, 2022, ForwardHealth has added POS code 10 and revised the description for POS code 02. Complete descriptions are as follows:
- POS code 02: Telehealth Provided Other Than in Patient’s Home—The location where health services and health related services are provided or received through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
- POS code 10: Telehealth Provided in Patient’s Home—The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
GEOGRAPHIC LIMITS
Effective for Dates on or After Mar. 1, 2022
FACILITY/TRANSMISSION FEE
In addition to reimbursement to the distant site provider, ForwardHealth reimburses an originating site facility fee for the staff and equipment at the originating site requisite to provide a service via telehealth. Eligible providers who serve as the originating site should bill the facility fee with HCPCS procedure code Q3014 (Telehealth originating site facility fee). Modifier GT, FQ, or 93 should not be included with procedure code Q3014.
Eligible providers who bill on a professional claim form should bill HCPCS procedure code Q3014 with a POS code that represents where the member is located during the service. The POS must be a ForwardHealth-allowable originating site for HCPCS procedure code Q3014 in order to be reimbursed for the originating site fee. Billing-only provider types must include an allowable rendering provider on the claim form. The originating site fee is reimbursed based on a maximum allowable fee.
Eligible providers who bill on an institutional claim form should bill Q3014 as a separate line item with the appropriate revenue code 0780. ForwardHealth will reimburse hospitals for the facility fee based on the standard hospital reimbursement methodology. ForwardHealth will reimburse these providers for the facility fee based on the provider’s standard reimbursement methodology.
An originating site facility fee is not a FQHC or RHC reportable encounter on the cost report. Any reimbursement for the originating site facility fee must be reported as a deductive value on the cost report.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Nov. 2022).
CHCs should submit claims for originating site services on a professional claim form with HCPCS procedure code Q3014 (Telehealth originating site facility fee) and a POS code that represents where the member is located during the service. Modifier GT should not be included with procedure code Q3014 for originating site services to be considered under the PPS reimbursement method. ForwardHealth will not separately reimburse the CHC for originating site services because all costs for providing originating site services have already been incorporated into the PPS rates for CHCs. However, claims billed by CHCs for originating site services may be used for future rate setting purposes, and CHC costs associated with telehealth services may be reported for change in scope adjustment consideration.
SOURCE: WI ForwardHealth Online Handbook, Telehealth for Community Health Centers. (Accessed Nov. 2022).
Allowable Originating Site Fee Expansion
The originating site is where the member is located during a telehealth visit. Only the provider at the originating site can bill for an originating site fee for hosting the member. The originating site should not use telehealth modifiers on the claims since all services are provided in-person. The distant site is where the provider is located during the telehealth visit. The provider who is providing health care services to the member via telehealth cannot bill the originating site fee because they are not hosting the member.
Beginning March 1, 2022, the following locations are eligible for the originating site fee under permanent telehealth policy:
- Office or clinic:
- Medical
- Dental
- Therapies (physical therapy, occupational therapy, speech and
language pathology)
- Behavioral and mental health agencies
- Hospital
- Skilled nursing facility
- Community mental health center
- Intermediate care facility for individuals with intellectual disabilities
- Pharmacy
- Day treatment facility
- Residential substance use disorder treatment facility
Although FQHCs are not directly reimbursed an originating site fee, HCPCS procedure code Q3014 should be billed for tracking purposes and for consideration in any potential future changes in scope.
To receive reimbursement, the originating site must:
- Utilize an interactive audiovisual telecommunications system that permits real-time communication between the provider at the distant site and the member at the originating site.
- Be in a physical location that ensures privacy
- Provide access to broadband internet with sufficient bandwidth to transmit audio and video data.
- Provide access to support staff to assist with technical components of the telehealth visit.
- Be compliant with Health Insurance Portability and Accountability Act of 1996 standards.
See bulletin for additional documentation requirements.
Last updated 11/21/2022
Miscellaneous
The department may not require a certified provider of Medical Assistance that provides a reimbursable service to obtain an additional certification or meet additional requirements solely because the service was delivered through telehealth, except that the department may require, by rule, that the transmission of information through telehealth be of sufficient quality to be functionally equivalent to face-to-face contact. The department may apply any requirement that is applicable to a covered service that is not provided through telehealth to any service.
SOURCE: WI Statute Sec. 49.45 (61)(e), (Accessed Nov. 2022).
Claims for telehealth services must include all modifiers required by coverage policy, in addition to POS code 02 or 10 and the GT, FQ, or 93 modifier, in order to reimburse the claim correctly.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Nov. 2022).
The following cannot be billed to the member:
Telehealth equipment like tablets or smart devices
- Charges for mailing or delivery of telehealth equipment
- Charges for shipping and handling of:
- Diagnostic tools
- Equipment to allow the provider to assess, diagnose, repair, or set up medical supplies online such as hearing aids, cochlear implants, power wheelchairs, or other equipment
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. & ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
School-Based Services
As part of the IEP team meeting, the IEP team should determine if the service delivered by telehealth meets the ForwardHealth definition of functionally equivalent to be reimbursed. The decision to utilize telehealth as a delivery mode must be documented in the IEP in the section the IEP team determines appropriate.
Documentation requirements for a telehealth service are the same as for an in-person visit and must accurately reflect the service rendered.
Documentation must identify the delivery mode of the service when provided via telehealth using the IEP team’s chosen term and document whether the service was provided via audio-visual telehealth or audio-only telehealth.
SOURCE: ForwardHealth Update, No. 2022-02, January 2022. (Accessed Nov. 2022).
“Functionally equivalent” means that when a service is provided via telehealth, the transmission of information must be of sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth, ForwardHealth Update No. 2022-01, Jan. 2022, & ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Last updated 11/21/2022
Out of State Providers
ForwardHealth policy for services provided via telehealth by out-of-state providers is the same as ForwardHealth policy for services provided face to face by out-of-state providers. Out-of-state providers who do not have border status enrollment with Wisconsin Medicaid are required to obtain PA before providing services via telehealth to BadgerCare Plus or Medicaid members.
Note: Wisconsin Medicaid is prohibited from paying providers located outside of the United States and its territories, including the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Nov. 2022).
Last updated 11/21/2022
Overview
Newly passed statute requires Wisconsin’s Medicaid program to provide coverage for Telehealth services, as defined under 42 USC 1395m (m) (4) (F), remote physiologic monitoring, remote evaluation of pre-recorded patient information, brief communication technology-based services, care management services delivered through telehealth and any other telehealth or communication technology-based services.
ForwardHealth has revamped their Medicaid reimbursement policy to allow certain CPT/HCPCS codes to be reimbursable via telehealth under certain circumstances. Audio-only is also allowed when audio-visual telehealth is not possible. Certain remote patient monitoring reimbursement codes are also now reimbursable. Interprofessional consultations (e-consults) are reimbursable by both the treating and consulting provider under the outlined policy requirements and limitations.
Last updated 11/21/2022
Remote Patient Monitoring
POLICY
Except as provided by the department by rule, remote patient monitoring of a Medical Assistance recipient in which the medical data pertains to a Medical Assistance recipient must be reimbursed.
Except as provided by the department by rule, services that are covered under Medicare for which the federal department of health and human services provides Medical Assistance federal financial participation and that are remote physiologic monitoring shall be reimbursed.
SOURCE: WI Statute Sec. 49.45 (61). (Accessed Nov. 2022).
Remote physiologic monitoring is the collection and interpretation of a member’s physiologic data, such as blood pressure or weight checks, that are digitally transmitted to a physician, nurse practitioner, or physician assistant for use in the treatment and management of medical conditions that require frequent monitoring. Such conditions include congestive heart failure, diabetes, chronic obstructive pulmonary disease, wound care, polypharmacy, and mental or behavioral problems. It is also used for members receiving technology-dependent care, such as continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding.
The following policy requirements apply for remote physiologic monitoring services:
- Only physicians, nurse practitioners, and physician assistants enrolled in ForwardHealth are eligible to render and submit claims for remote physiologic services.
- The member’s consent for remote physiologic monitoring services must be documented in the member’s medical record.
- The provider must document how remote physiologic monitoring is tied to the member-specific needs and will assist the member to achieve the goals of treatment.
- Services are not separately reimbursable if the services are bundled or covered by other procedure codes (for example, continuous glucose monitoring is covered under CPT procedure code 95250 and should not be submitted under CPT procedure codes 99453–99454).
- CPT procedure codes 99453 and 99454 can be used for blood pressure remote physiologic monitoring if the device used to measure blood pressure meets remote physiologic monitoring requirements. If the member self-reports blood pressure readings, the provider must instead submit self-measured blood pressure monitoring CPT procedure codes 99473–99474.
- CPT procedure code 99457 should be used when the physician, nurse practitioner, or physician assistant uses medical decision making based on interpreted data received from a remote physiologic monitoring device to assess the member’s clinical stability, communicate the results to the member, and oversee the management and/or coordination of services as needed.
Providers are expected to follow CPT guidelines.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Nov. 2022).
Only synchronous (two-way, real-time, interactive communications) and remote physiological monitoring services identified under permanent policy may be reimbursed when provided via telehealth effective on the first day of the first month after the federal public health emergency related to the COVID-19 pandemic expires. For example, if the public health emergency ends on April 12, 2022, permanent policy would become effective for dates of service on and after May 1, 2022. Temporary telehealth policy will remain in effect until the switch to permanent policy occurs when ForwardHealth will require providers
to follow permanent billing guidelines for synchronous telehealth and remote physiological monitoring services. Telehealth-related updates
to the ForwardHealth Online Handbook will be available following the implementation of permanent policy.
Remote physiologic monitoring is the collection and interpretation of a member’s physiologic data, such as blood pressure or weight checks, that are digitally transmitted to a physician, nurse practitioner, or physician assistant for use in the treatment and management of medical conditions that require frequent monitoring.
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
CONDITIONS
Conditions include congestive heart failure, diabetes, chronic obstructive pulmonary disease, wound care, polypharmacy, and mental or behavioral problems. It is also used for members receiving technology-dependent care, such as continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Nov. 2022). & ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
PROVIDER LIMITATIONS
Provided by a physician, nurse practitioner, or physician assistant.
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Only physicians, nurse practitioners, and physician assistants enrolled in ForwardHealth are eligible to render and submit claims for remote physiologic services.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Nov. 2022).
OTHER RESTRICTIONS
The device used to capture a member’s physiologic data must meet the Food and Drug Administration definition of a medical device. To submit claims for CPT procedure codes 99453–99458, the members’ physiologic data must be wirelessly synced so it can be evaluated by the physician, nurse practitioner, or physician assistant. Transmission can be synchronous or asynchronous. (Data does not have to be transmitted in real time as long as it is automatically updated on an ongoing basis for the provider to review.)
SOURCE: ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
Last updated 11/21/2022
Store and Forward
POLICY
Except as provided by the department by rule, asynchronous telehealth services in which the medical data pertains to a Medical Assistance recipient must be reimbursed.
Except as provided by the department by rule, services that are covered under Medicare for which the federal department of health and human services provides Medical Assistance federal financial participation and that are remote evaluation of prerecorded information shall be reimbursed.
SOURCE: WI Statute Sec. 49.45 (61). (Accessed Nov. 2022).
Services that are not covered when delivered in person are not covered as telehealth services. In addition, services that are not functionally equivalent to the in-person service when provided via telehealth are not covered.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth (Accessed Nov. 2022).
Interprofessional Consultations (E-Consults)
An interprofessional consultation or e-consult is an assessment and management service in which a member’s treating provider requests the opinion and/or treatment advice of a provider with specific expertise (the consultant) to assist the treating provider in the diagnosis and/or management of the member’s condition without requiring the member to have face-to-face contact with the consultant. Both the treating and consulting providers may be reimbursed for the e-consult as described below.
Policy Requirements and Limitations
Consulting Providers
Consulting providers must be physicians enrolled in Wisconsin Medicaid as an eligible rendering provider. Consulting providers may bill CPT procedure codes 99446–99449 and 99451 under the following limitations:
- Services are not covered if the consultation leads to a transfer of care or other face-to-face service within the next 14 days or next available date of the consultant. Additionally, if the sole purpose of the consultation is to arrange a transfer of care or other face-to-face service, these procedure codes should not be submitted.
- Consulting services are covered once in a seven-day period.
Treating Providers
Treating providers may be a physician, nurse practitioner, physician assistant, or podiatrist enrolled in Wisconsin Medicaid as an eligible rendering provider. Treating providers may bill CPT procedure code 99452 as a covered service once in a 14-day period.
Both the consulting and treating providers must be enrolled in Wisconsin Medicaid to receive reimbursement for the e-consult and the consultation must be medically necessary.
Providers are expected to follow CPT guidelines including that the CPT procedure codes should not be submitted if the consulting provider saw the member in a face-to-face encounter within the previous 14 days.
Documentation Requirements
The following documentation requirements apply for e-consults:
- The consulting provider’s opinion must be documented in the member’s medical record.
- The written or verbal request for a consultation by the treating provider must be documented in the member’s medical record including the reason for the request.
- Verbal consent for each consultation must be documented in the member’s medical record. The member’s consent must include assurance that the member is aware of any applicable cost-sharing.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth & ForwardHealth Update Dec. 2021 updated Oct. 2022, No. 2021-50. (Accessed Nov. 2022).
ELIGIBLE SERVICES
No Reference Found
GEOGRAPHIC LIMITS
No Reference Found
TRANSMISSION FEE
No Reference Found
