Last updated 02/28/2021
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.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Feb. 2021).
“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 Feb. 2021).
Last updated 02/28/2021
Live Video
POLICY
Statute requires reimbursement for any benefit that delivered via interactive telehealth that is a covered benefit under Medicaid as provided by the department by rule. The ForwardHealth provider manual currently only allows for certain covered services to be provided via live video telehealth.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Feb. 2021).
ELIGIBLE SERVICES/SPECIALTIES
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 Feb. 2021).
ForwardHealth only covers telehealth delivery of individual services. For those procedure codes that can be used for either individual or group services, providers may not submit claims for telehealth delivery of group services. Allowable providers may be reimbursed, as appropriate, for the following services (and applicable procedure codes) provided through telehealth. See Manual for covered telehealth CPT and HCPCS codes.
ForwardHealth reimburses providers for telestroke services.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Feb. 2021).
ELIGIBLE PROVIDERS
Allowable providers:
- Audiologists
- Individual mental health and substance abuse practitioners not in a facility certified by the DQA (Division of Quality Assurance)
- Nurse midwives
- Nurse practitioners
- Ph.D. psychologists
- Physician assistants
- Physicians
- Psychiatrists
- Professionals providing services in mental health or substance abuse programs certified by the DQA
Ancillary Providers
Claims for services provided via telehealth by distant site ancillary providers should be billed 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.
Tribal FQHCs and RHCs
They may serve as originating site and distant site providers for telehealth services. See manual for details.
Tribal 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 (modifier indicating telehealth) 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 Feb. 2021).
Community Health Centers (CHCs)
CHCs may serve as originating site and distant site providers for telehealth services.
Services billed with modifier GT (modifier indicating telehealth) 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. Telehealth for Community Health Centers. (Accessed Feb. 2021).
ELIGIBLE SITES
For DOS on or after March 1, 2020, ForwardHealth will allow coverage of telehealth for any originating site. However, only the following originating sites will be 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:
- Community Health Centers (CHC)
- Federally Qualified Health Centers (FQHC)
- Rural Health Clinics (RHC)
Telehealth services that are medical in nature and would otherwise be coded as an office visit or consultation evaluation and management visit are covered for members residing in a skilled nursing facility.
Community Health Centers, Tribal FQHCs and RHCs
The originating site facility fee is not a tribal 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.
For CHCs, originating site services should be billed, but no reimbursement will be issued as all costs for providing originating site services have already been incorporated into the PPS rates for CHCs. Claims billed by CHCs for originating site services may be used for future rate setting purposes.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth & Telehealth for Community Health Centers (Accessed Feb. 2021).
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 Feb. 2021).
GEOGRAPHIC LIMITS
No Reference Found
FACILITY/TRANSMISSION FEE
Reimbursement for facility fee using HCPCS procedure code Q3014. Modifier GT should not be included with procedure code Q3014.
An originating site facility fee is not a tribal FQHC or RHC reportable encounter.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Feb. 2021).
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 Feb. 2021).
Last updated 02/28/2021
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 Feb. 2021).
POS code 02 required.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Feb. 2021).
Last updated 02/28/2021
Overview
Newly passed statute requires Wisconsin’s Medicaid program to provide coverage for any benefit delivered via interactive video. ForwardHealth is also required to provide reimbursement for remote patient monitoring, asynchronous telehealth and other communication-based technology covered by Medicare. However, ForwardHealth currently allows for only certain covered services to be provided via telehealth via interactive telehealth, specifically excludes store-and-forward from coverage and does not mention remote patient monitoring.
Last updated 02/28/2021
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 Feb. 2021).
No reimbursement. Services must be functionally equivalent to face-to-face.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Feb. 2021).
CONDITIONS
No Reference Found
PROVIDER LIMITATIONS
No Reference Found
OTHER RESTRICTIONS
No Reference Found
Last updated 02/28/2021
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 Feb. 2021).
No reimbursement. Services must be functionally equivalent to face-to-face.
SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Feb. 2021).
ELIGIBLE SERVICES
No Reference Found
GEOGRAPHIC LIMITS
No Reference Found
TRANSMISSION FEE
No Reference Found
