Author: GDIT, (800) 688-6696
NOTE: SPECIAL BULLETIN COVID-19 #21 has been replaced in its entirety by SPECIAL BULLETIN COVID-19 #36: Telehealth Clinical Policy Modifications - Outpatient Specialized Therapies and Dental Services
Effective March 30, 2020, NC Medicaid is temporarily modifying its Telemedicine and Telepsychiatry Clinical Coverage Policy to better enable the delivery of remote care to Medicaid and NC Health Choice beneficiaries. These temporary changes will be retroactive to March 10, 2020, and will end the earlier of the cancellation of the North Carolina state of emergency declaration or when this policy is rescinded. This Medicaid Bulletin outlines guidance for outpatient specialized therapies (physical therapy, occupational therapy, speech language therapy, and audiology) and dental services that can now be delivered via telehealth.
NC Medicaid has eliminated the restriction that teletherapy and teledental services cannot be conducted via “video cell phone interactions.” These services can now be delivered via any HIPAA-compliant, secure technology with audio and video capabilities, including (but not limited to) smart phones, tablets and computers. In addition, the Office of Civil Rights (OCR) at Health and Human Services (HHS) recently issued guidance noting that “covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.”
NC Medicaid has considered the recommendations of related licensing boards and associations, and conducted a close evaluation of in-person therapy and dental service codes to develop the policy modifications outlined in this bulletin. NC Medicaid will continue to release telehealth policy provisions and evaluate this policy throughout the state of emergency period.
Outpatient Specialized Therapy Services – Physical Therapy, Occupational Therapy, Speech Language Therapy, and Audiology
The following are policy modifications related to outpatient specialized therapy services:
- Teletherapy, Eligible Providers, and Technology Requirements
- Outpatient specialized therapy providers -- including physical therapists, occupational therapists, speech language therapists, and audiologists -- may deliver select evaluation and treatment services via teletherapy to new or established patients. Teletherapy refers to the use of two-way real-time interactive audio and video to provide and support health care when participants are in different physical locations; audio-only interactions are not considered teletherapy.
- Standard of Teletherapy Care
- Therapists must ensure that the services can safely and effectively be delivered via teletherapy in alignment with NC Medicaid Clinical Coverage Policies 10A, Outpatient Specialized Therapies, and 10B, Independent Practitioners. Therapists must consider a client’s behavioral, physical, and cognitive abilities to participate in services provided via teletherapy.
- The patient’s safety must be carefully considered for the complexity of the services provided. In addition, in situations in which a caregiver or facilitator is necessary to assist with the delivery of the teletherapy, their ability to assist and their safety should be considered as well.
- Delivery of therapy services via teletherapy must conform to professional standards including but not limited to ethical practice, scope of practice, and other relevant federal, state, and institutional policies and requirements including Practice Act and Licensing Board rules.
- Prior Authorization
- Prior authorization requirements for services delivered in-person will still apply when delivered via teletherapy. Teletherapy can be provided under existing prior authorizations.
See “Temporary Modifications to Attachment A” for a list of specialized therapy service codes that can be billed as teletherapy services, and additional coding and billing guidance.
Teledentistry Services
The following are policy modifications related to teledentistry services. Teledentistry refers to the use of telehealth systems and methodologies in dentistry.
- Use of Teledentistry Codes
- During the COVID-19 pandemic, enrolled dentists should limit their use of teledentistry services to triage or evaluate beneficiaries with urgent or emergent oral health problems. This is consistent with ADA, CDC and CMS recommendations regarding postponement of all elective or routine dental care until further notice.
- Dentists cannot delegate to a registered dental hygienist or another staff member the responsibility of contact with a beneficiary that will be reported as a teledentistry service. Additionally, contact for administrative purposes such as scheduling, triage, or routine post-operative care cannot be reported as teledentistry.
- Dental treatment rendered through teledentistry must be documented in the patient’s record including the date/time/duration of encounter, reasons for the encounter (documentation of the emergent or urgent need), technology used, records reviewed, diagnosis, and treatment recommendations.
- Prior approval limitations have been removed and are not required for any of the teledentistry services listed below.
- Code-specific Guidance
- D9995 Teledentistry – synchronous; real-time encounter
Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.- Under the existing clinical policy, Medicaid-enrolled dentists may render provider to provider teledentistry services via synchronous, live audio and video transmission in accordance with Code on Dental Procedures and Nomenclature (CDT) code D9995.
- Under this clinical policy modification, NC Medicaid is expanding this code to also cover provider to patient teledentistry services. A dentist is not required to be present with a patient during provider to patient synchronous teledentistry encounters.
- D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review
Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.- Under this clinical policy modification, NC Medicaid has added a new teledentistry code, D9996, to cover and reimburse for asynchronous teledentistry encounters, such as store and forward or eConsults.
- This code can be billed for both provider to provider and provider to patient encounters.
- There is a frequency limit applied the use of this code; for both provider to provider and provider to patient asynchronous teledentistry encounters, providers may not bill this code more than once per week, per patient.
- Oral Evaluation Codes
D0140 Limited oral evaluation – problem focused
An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive procedures may be required on the same date as the evaluation.
D0170 Re-evaluation – limited, problem focused (established patient; not post-operative visit)
Assessing the status of a previously existing condition. - Additional Reporting Guidance
- For synchronous teledentistry encounters: Dentists may report one of the oral evaluation codes above if the synchronous transmission includes enough live video, recorded video or images communicated via a mobile communication device to allow the dentist to make a diagnosis.
- For asynchronous teledentistry encounters: Dentists may report one of the oral evaluation codes above if the asynchronous transmission includes enough video and/or photographic evidence for the dentist to make a diagnosis.
- D9995 Teledentistry – synchronous; real-time encounter
- Guidance from the American Dental Association on Teledentistry
- Website: ADA Coronavirus Center for Dentist
- Link: COVID-19 Resources for Dentists
- Document: COVID-19 Coding and Billing Guidance
See “Temporary Modifications to Attachment A” for additional coding and billing guidance.
Temporary Modifications to Attachment A: Claims-Related Information
Effective March 30, 2020, through the conclusion of the State of Emergency related to COVID-19, NC Medicaid is temporarily modifying Attachment A of its Telemedicine and Telepsychiatry Clinical Coverage Policy 1-H to better enable the delivery of remote specialized therapy and dental care to Medicaid beneficiaries. Provider(s) shall comply with the “NCTracks Provider Claims and Billing Assistance Guide,” Medicaid Bulletins, fee schedules, NC Medicaid’s clinical coverage policies and any other relevant documents for specific coverage and reimbursement for Medicaid and NC Health Choice:
A. Claim Type
Professional (CMS-1500/837P transaction)
Institutional (UB-04/837I transaction)
Dental (ADA 2019/837D transaction)
B. International Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS)
Provider(s) shall report the ICD-10-CM and Procedural Coding System (PCS) to the highest level of specificity that supports medical necessity. Provider(s) shall use the current ICD-10 edition and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for code description, as it is no longer documented in the policy.
C. Code(s)
Provider(s) shall report the most specific billing code that accurately and completely describes the procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology (CPT), Code on Dental Procedures and Nomenclature (CDT), Health Care Procedure Coding System (HCPCS) and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for the code description, as it is no longer documented in the policy.
If no such specific CPT, CDT or HCPCS code exists, then the provider(s) shall report the procedure, product or service using the appropriate unlisted procedure or service code.
The following new and established patient evaluation and treatment codes, when provided via teletherapy, may be billed by physical therapists.
| Codes | Description (See 2020 CPT Code Book for Complete Details) |
| 97161 | Physical therapy evaluation: low complexity, typically, 20 minutes are spent face-to-face with the patient and/or family. |
| 97162 | Physical therapy evaluation: moderate complexity; typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 97163 | Physical therapy evaluation; high complexity; typically, 45 minutes are spent face-to-face with the patient and/or family. |
| 97164 | Re-evaluation of physical therapy established plan of care; typically, 20 minutes are spent face-to-face with the patient and/or family. |
| 97750 | Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes. |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. |
| 97116 | Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes |
| 97535 | Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes |
| 97542 | Wheelchair management (e.g., assessment, fitting, training), each 15 minutes |
| 97763 | Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies) and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes |
| 95992 | Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver), per day |
The following new and established patient evaluation and treatment codes, when provided via teletherapy, may be billed by occupational therapists.
| Codes | Description (See 2020 CPT Code Book for Complete Details) |
| 97165 | Occupational therapy evaluation, low complexity; typically, 30 minutes are spent face-to-face with patient and/or family. |
| 97166 | Occupational therapy evaluation, moderate complexity, requiring these components; typically, 45 minutes are spent face-to-face with patient and/or family. |
| 97167 | Occupational therapy evaluation, high complexity, requiring these components; typically, 60 minutes are spent face-to-face with patient and/or family. |
| 97168 | Re-evaluation of occupational therapy established plan of care; typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 97750 | Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes. |
| 92065 | Orthoptic and/or pleoptic training, with continuing medical direction and evaluation |
| 92526 (feeding only) | Treatment of swallowing dysfunction and/or oral function for feeding |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities |
| 97116 | Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes |
| 97535 | Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes |
| 97542 | Wheelchair management (e.g., assessment, fitting, training), each 15 minutes |
| 97763 | Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies) and/or trunk, subsequent orthotic(s)/prosthetics(s) encounter, each 15 minutes |
The following new and established patient evaluation and treatment codes, when provided via teletherapy, may be billed by speech language therapists.
| Codes | Description (See 2020 CPT Code Book for Complete Details) |
| 92521 | Evaluation of speech fluency (e.g., stuttering, cluttering) |
| 92522 | Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); |
| 92523 | Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language) |
| 92524 | Behavioral and qualitative analysis of voice and resonance |
| 92607 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour |
| 92608 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes |
| 96125 | Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 92526 (feeding only) | Treatment of swallowing dysfunction and/or oral function for feeding |
| 92609 | Therapeutic services for the use of speech-generating device, including programming and modification |
| 92630 | Auditory rehabilitation; prelingual hearing loss |
| 92633 | Auditory rehabilitation; postlingual hearing loss |
The following established patient treatment codes, when provided via teletherapy, may be billed by audiologists.
| Codes | Description (See 2020 CPT Code Book for Complete Details) |
| 92630 | Auditory rehabilitation; prelingual hearing loss |
| 92633 | Auditory rehabilitation; postlingual hearing loss |
The following teledentistry codes may be billed by dentists.
| Codes | Description (See 2020 CPT Code Book for Complete Details) |
| D9995 | Teledentistry – synchronous; real-time encounter. Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service. |
| D9996 | Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service. |
| D0140 | Limited oral evaluation – problem focused. An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive procedures may be required on the same date as the evaluation. Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, etc. |
| D0170 | Re-evaluation – limited, problem focused. (established patient; not post-operative visit) Assessing the status of a previously existing condition. |
CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in effect at the time of service.
CDT: The provider(s) shall refer to and comply with the Code on Dental Procedures and Nomenclature as documented in the current CDT in effect at the time of service.
HCPCS: The provider(s) shall refer to and comply with the Instructions for Use of HCPCS National Level II Codes, Unlisted Procedure or Service and Special Report as documented in the current HCPCS edition in effect at the time of service.
D. Modifiers
Provider(s) shall follow applicable modifier guidelines. Teledentistry codes do not require modifiers.
Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for services performed telephonically or through email or patient portal.
Modifier CR (catastrophe/disaster related) must be appended to all claims for CPT and HCPCS codes listed in this policy to relax frequency limitations defined in code definitions. All specialized therapy services should include a CR modifier.
E. Billing Unit
Provider(s) shall report the appropriate code(s) used which determines the billing unit(s).
F. Place of Service
Teletherapy and teledental claims should be filed with place of service 02 (telehealth).
G. Co-payments
For Medicaid refer to Medicaid State Plan, Attachment 4.18-A, page 1, located at https://medicaid.ncdhhs.gov/
For NC Health Choice refer to G.S. 108A-70.21(d), located at http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_108A/GS_108A-70.21.html.
H. Reimbursement
Provider(s) shall bill their usual and customary charges. For a schedule of rates, refer to: https://medicaid.ncdhhs.gov/
When the GT modifier is appended to a code billed for professional services, the service is paid at 100% of the allowed amount of the fee schedule.
- For hospitals, this is a covered service for both inpatient and outpatient and is part of the normal hospital reimbursement methodology.
- Reimbursement for these services is subject to the same restrictions as face-to-face contacts (such as place of service, allowable providers, multiple service limitations, prior authorization) unless otherwise noted in this policy.