SPECIAL BULLETIN COVID-19 #2: General Guidance and Policy Modifications

NC Medicaid is committed to ensuring our beneficiaries continue to receive Medicaid and NC Health Choice services with no interruptions or delays due to the novel coronavirus (COVID-19) outbreak. This includes making it easier for health care providers to deliver Medicaid services by temporarily modifying certain policy conditions and expanding coverage to include additional forms of clinical service. These changes are designed to both facilitate access for patients experiencing COVID-19 symptoms and to limit close contact for routine care, particularly for those at higher risk of severe illness. Additionally, it is critically important to keep our health care workforce accessible to provide care in creative ways due to prolonged quarantines following exposures.

NC Medicaid is working closely with community, state and federal partners to evaluate additional approaches should they be needed in the future. Additional changes to NC Medicaid policies will be shared through future Medicaid Bulletins and NCTracks provider emails, and will be posted to the Medicaid COVID-19 webpage at medicaid.ncdhhs.gov/coronavirus. Other COVID-19 information and resources are on the NC Department of Health and Human Services website at https://www.ncdhhs.gov/divisions/public-health/coronavirus-disease-2019-covid-19-response-north-carolina

Home Visits: Existing Policy

Medicaid has existing clinical policies to reimburse for home visits. Providers are encouraged to create access with home visits especially for vulnerable populations and group living.

Copays: Existing Policy

Providers are reminded that copays are not required at the time of the office visit. A Medicaid patient should never be turned away for inability to pay a copay.

Virtual Patient Communications: Temporary Flexibilities Effective March 13, 2020

Effective Friday, March 13, 2020, NC Medicaid is offering reimbursement for virtual patient communication and telephonic evaluation and management for the following beneficiaries seeking care where they are already an established patient:

• Beneficiaries who are actively experiencing mild symptoms of COVID-19 (fever, cough, shortness of breath) prior to going to the emergency department, urgent care or other health care facility.
• Beneficiaries who need routine, uncomplicated follow up and who are not currently experiencing symptoms of COVID-19.
• Beneficiaries requiring behavioral health assessment and management.

The following virtual patient communication and telephonic evaluation and management services must be rendered by a physician, nurse practitioner, certified nurse midwife or physician assistant actively enrolled in NC Medicaid and NCTracks. Virtual patient communication or telephonic evaluation and management by staff other than those listed should not be submitted for reimbursement. Services are to be rendered only to established patients or legal guardian of an established patient.

Note: Modifier CR should be used with the CPT or HCPCS codes listed in this bulletin. The use of modifier CR will bypass time limitations (7 day and 24 hour) and editing on these codes related to COVID-19.

The following codes will be used to report virtual patient communication for beneficiaries who are actively experiencing mild symptoms of COVID-19 (fever, cough, shortness of breath) prior to going to the emergency department, urgent care or other health care facility:

• G2012: Brief communication technology-based service; e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days or not leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

The following virtual patient communication codes will be used to report telephonic evaluation and management for beneficiaries who need routine, uncomplicated follow up for chronic disease or routine primary care and who are not currently experiencing symptoms of COVID-19:

• 99441: Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management (E/M) services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
• 99442: Telephone evaluation and management service by a physician or other qualified health care professional who may report E/M services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.
• 99443: Telephone evaluation and management service by a physician or other qualified health care professional who may report E/M services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.

The following codes will be used to report behavioral health telephonic assessment and management by a licensed non-physician behavioral health professional (licensed clinical social worker (LCSW): licensed clinical social worker associate (LCSW-A); licensed professional counselor (LPC); licensed professional counselor associate (LPC-A); licensed marriage and family therapist (LMFT); licensed marriage and family therapist associate (LMFT-A); licensed clinical addiction specialist (LCAS); licensed clinical addiction specialist associate (LCAS-A); psychologist and licensed psychological associate (LPA):

• 98966: Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days not leading to an assessment and management service or procedure with the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
• 98967: Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days not leading to an assessment and management service or procedure with the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.
• 98968: Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days not leading to an assessment and management service or procedure with the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.

Federally Qualified Health Centers and Rural Health Centers

For reporting:

• Virtual patient communication for beneficiaries who are actively experiencing mild symptoms of COVID-19 (fever, cough, shortness of breath) prior to going to the emergency department, urgent care or other health care facility.
• Telephonic evaluation and management for beneficiaries with chronic health conditions who need routine, uncomplicated follow up and who are not currently experiencing symptoms of COVID-19 but who are at higher risk of complications should they come in with the virus.

Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) should use the following code:

• G0071: Payment for communication technology-based services for 5 minutes or more of a virtual (not face-to-face) communication between an  RHC or FQHC practitioner and RHC or FQHC patient.

The Centers for Medicare & Medicaid Services has determined that RHCs and FQHCs can receive payment for virtual communication services when at least 5 minutes of communication technology-based or remote evaluation services are furnished by an RHC or FQHC practitioner to a patient who has had an RHC or FQHC billable visit within the previous year, and both of the following requirements are met:

• The medical discussion or remote evaluation is for a condition not related to an RHC or FQHC service provided within the previous 7 days, and
• The medical discussion or remote evaluation does not lead to an RHC or FQHC visit within the next 24 hours or at the soonest available appointment.

ICD-10 Diagnosis Codes

ICD-10 diagnosis codes to be reported for Coronavirus Virtual Patient Communication and Telephonic Evaluation and Management codes include:

• If the visit is for COVID-19 symptoms, contact with and (suspected) exposure to other viral communicable disease: Z20.828
• Additionally, use of modifier CR for the CPT or HCPCS codes listed in this bulletin will bypass time limitations (7 day and 24 hour) and editing on these codes related to COVID-19.   
   

Pharmacy: Temporary Flexibilities Effective March 13, 2020

Recommendations for social distancing in response to the COVID-19 present situations where Medicaid and Health Choice beneficiaries may benefit from an early refill or expanded quantity of their prescription medications. In these situations, NC Medicaid enrolled pharmacy providers should resubmit these claims with “09” (Emergency Preparedness) in the PA Type Code field and a valid value for an E.R. override in the Reason for Service, Professional Service and Result of Service fields to override a denial for an early refill. Do not place any values in the Submission Clarification Code field.

This override code will allow for early refills and will also allow for coverage of up to a 90-day supply of the medication. Be aware that NC Medicaid policy allows a 90-day supply to be filled when the prescription is either written for a 90-day supply or has enough refills remaining to fill for up to 90 days.

• Note that these edit changes do not apply to controlled substances. Additionally, providers are encouraged to follow all applicable state and federal laws and regulations for controlled substances.
• If necessary, up to a 14-day emergency supply can be billed for any pharmacy claim requiring prior approval when no active prior approval is showing in NCTracks. The pharmacy provider should resubmit these claims with “09” (Emergency Preparedness) in the PA Type Code field and “03” in the Level of Service Field.
• For beneficiaries in the Pharmacy Lock-in Program needing emergency supplies of Lock-In program-related medications, up to a 14-day emergency supply can be billed with “09” (Emergency Preparedness) in the PA Type Code field and “03” in the Level of Service Field. This override is only valid once per beneficiary per year. Beneficiaries and providers may also contact the NCTracks call center to change either the preferred Lock-In pharmacy or preferred Lock-In prescriber on an emergency basis.
• Copay requirements are still applicable to these pharmacy claims.

Providers may submit any information related to market shortages of medications directly to NC Medicaid staff at Medicaid.PDL@dhhs.nc.gov.

Durable Medical Equipment: Temporary Flexibilities Effective March 13, 2020

Effective March 13, 2020, Medicaid and NC Health Choice coverage was added for HCPCS code A4928 - surgical mask, per 20. If medically necessary, this item may be provided to beneficiaries with respiratory infections and their caregivers without first seeking prior authorization (PA).

Also effective March 13, 2020, if medically necessary, the respiratory equipment and supplies listed below that typically require PA may be provided to beneficiaries with respiratory infections without first seeking PA.

Effective March 13, 2020, if medically necessary, quantity limits on the following supplies may be exceeded when provided to beneficiaries with respiratory infections without first seeking PA:

If typically required, providers are encouraged to obtain PA if it is reasonable to do so and it will not delay the provision of medically necessary equipment and supplies. Providers must maintain documentation of medical necessity and all records per subsection 7.2, Record Keeping of clinical coverage policies 5A-2, Respiratory Equipment and Supplies, and/or 5A-3, Nursing Equipment and Supplies. All claims are subject to audit.