SPECIAL BULLETIN COVID-19 #34: Telehealth Clinical Policy Modifications – Definitions, Eligible Providers, Services and Codes

Tuesday, April 7, 2020

Important Notes to Bulletin #34

SPECIAL BULLETIN COVID-19 #34 replaces the following Medicaid Bulletins in their entirety:

  • SPECIAL BULLETIN COVID-19 #9: Telehealth Provisions – Clinical Policy Modification
  • SPECIAL BULLETIN COVID-19 #19: Telehealth Provisions – Clinical Policy Modification
  • SPECIAL BULLETIN COVID-19 #28: [ADDENDUM to Bulletin #9 Effective March 20, 2020] : Telehealth Provisions – Clinical Policy Modification

Please note the change to F. Place of Service: Telemedicine and telepsychiatry claims should be filed with the provider’s usual place of service code per the appropriate clinical coverage policy and not Place of Service (POS) 02 (telehealth)

Please note the clarification that licensed psychologists and licensed psychological associates are permitted bill using codes for psychiatric diagnostic evaluation and psychotherapy. This was originally listed as “psychologists.”

New telehealth codes and guidance in Bulletin #34:

  • Services delivered through local education agencies (LEAs)
  • Services delivered through children’s developmental service agencies (CDSAs)
  • Diabetes self-management education 
  • Dietary evaluation and counseling
  • Medical lactation
  • Research-based behavioral health treatment for autism spectrum disorder

Contents

Background and General Guidance
Definitions
Telehealth Services

Virtual Patient Communication Services

Temporary Modifications to Attachment A: Claims-Related Information

Additional Resources
 

Background and General Guidance

NC Medicaid, in partnership with the DHHS Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMHDDSAS), has temporarily modified its Telemedicine and Telepsychiatry Clinical Coverage Policy to better enable the delivery of remote care to Medicaid and State-funded beneficiaries. These temporary changes are retroactive to March 10, 2020, and will end the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded, unless noted otherwise below. When the temporary modifications end, all face-to-face service requirements will resume.

Providers must ensure that Medicaid services outlined in this and other telehealth COVID-19 clinical policy bulletins can be safely and effectively delivered using telehealth in alignment with relevant NC Medicaid clinical coverage policies. Providers must consider a client’s behavioral, physical and cognitive abilities to participate in services provided using telehealth. The beneficiary’s safety must be carefully considered for the complexity of the services provided. 

In addition, in situations where a caregivers or facilitators are necessary to assist with the delivery of telehealth services, their ability to assist and their safety should also be considered. Delivery of services using telehealth 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. 

NC Medicaid has considered the recommendations of related licensing boards and associations and conducted a close evaluation of in-person service codes to develop the policy modifications outlined in this bulletin. 

NC Medicaid and DMHDDSAS continue to evaluate telehealth policies and will release temporary flexibilities and guidance as needed throughout the state of emergency. 
Specific guidance related to billing and coding is detailed in the section “Temporary Modifications to Attachment A.”
 

Definitions

  • Telehealth is the use of two-way real-time interactive audio and video to provide care and services when participants are in different physical locations. There are three types of telehealth: 
    • Telemedicine is the use of two-way real-time, interactive audio and video to provide and support health care when participants are in different physical locations. 
    • Telepsychiatry is the use of two-way real-time, interactive audio and video to provide and support psychiatric/behavioral health care when participants are in different physical locations. 
    • Teletherapy is the use of two-way real-time, interactive audio and video to provide and support specialized outpatient therapy care when participants are in different locations. 
  • Virtual Patient Communication is the use of technologies other than video to enable remote evaluation and consultation support between a provider and a patient or a provider and another provider. Covered virtual patient communication services include telephone conversations (audio only); virtual portal communications (e.g., secure messaging); and store and forward (e.g., transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).
     

Telehealth Services

Consistent with its existing policy, telehealth services (telemedicine, telepsychiatry and teletherapy) have coverage and payment parity with in-person care. Medicaid and NC Health Choice will continue to cover and reimburse all telemedicine interactions at a rate that is equal to in-person care as long as they meet the standard of care and are conducted over a secure HIPAA-compliant technology with live audio and video capabilities.

General Policy Modifications

The following are policy modifications related to telehealth:

  • Eligible Technologies
    • NC Medicaid has eliminated the restriction that telehealth 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.” 
  • Service Sites
    • Originating Site: There are no restrictions on originating sites (formerly known as spoke sites). Originating sites may include health care facilities, school-based health centers, community sites, the home or wherever the patient may be located. 
    • Distant Site: There are no restrictions on distant sites (formerly known as hub sites). Distant sites may be wherever the provider may be located. Providers must ensure that patient privacy is protected (e.g., taking calls from private, secure spaces; using headsets). Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes and Rural Health Centers (RHCs) are considered eligible distant sites and should follow the coding and billing guidelines in “Temporary Modifications to Attachment A” below.
  • Providers
    • Referring Providers: There are no longer any requirements related to referring providers. 
    • Eligible Providers: NC Medicaid has expanded the list of eligible distant site telemedicine and telepsychiatry providers to include clinical pharmacists, licensed clinical social workers (LCSW), licensed clinical mental health counselors (LCMHCs), licensed marriage and family therapists (LMFTs), licensed clinical addiction specialists (LCASs) and licensed psychological associates (LPAs). 
  • Authorization, Referrals and In-Person Examinations
    • Patients are not required to obtain prior authorization or have an initial in-person examination prior to receiving telemedicine or telepsychiatry services; however, when establishing a new relationship with a patient via either telemedicine or telepsychiatry, the provider must meet the prevailing standard of care and complete all appropriate exam requirements and documentation dictated by E/M coding guidelines.

Local Education Agencies (LEAs)

The following are policy modifications related to services delivered by LEAs to Medicaid beneficiaries in alignment with outpatient specialized therapies policy 10C, Local Education Agencies:

  • Eligible Services 
    • NC Medicaid requirements and standards for services delivered by LEAs are not modified when Medicaid-covered services are delivered via telehealth during the state of emergency. 
    • A select set of skilled interventions provided by LEAs may be delivered to Medicaid beneficiaries via telemedicine/telepsychiatry/teletherapy as a result of this clinical policy modification, including physical therapy, speech and language therapy, occupational therapy, audiology, psychological and counseling services. 
    • All psychological testing components and other therapeutic, psychological and counseling services may not be appropriate for telehealth delivery in all situations or for all student beneficiaries. Each student and situation must be assessed individually by the practitioner to determine if telehealth is appropriate and how to safely implement within regulation, scope of practice and policy.

See “Temporary Modifications to Attachment A” for a list of LEA service codes that can be billed as telehealth services, and additional coding and billing guidance.

Children’s Developmental Services Agencies (CDSAs) – NC Infant Toddler Program (NC ITP) Services

The following are policy modifications related to Medicaid-covered NC ITP services delivered by CDSAs and their contract providers:

  • Eligible Services 
    • NC Medicaid requirements and standards for NC ITP services provided by CDSAs in conjunction with contract providers are not modified when Medicaid-covered services are delivered via telehealth during the state of emergency. 
    • A select set of NC ITP services may be delivered to Medicaid beneficiaries via telehealth as a result of this clinical policy modification, including audiology, nutrition services, occupational therapy, physical therapy, psychological services, speech and language therapy, medical services, clinical social work, multidisciplinary evaluations and assessments, case management, community-based rehabilitative services (CBRS), and developmental testing. 
    • The delivery of outpatient specialized therapies (physical, occupational, speech and language, audiology) via teletherapy are subject to guidance outlined in Special Bulletin COVID-19 #36.
  • Eligible Providers
    • The following CDSA staff and their contract providers are eligible to deliver NC ITP services to new or established patients via telehealth: infant, toddler and family specialists, educational diagnosticians, speech and language therapists, audiologists, occupational therapists, physical therapists, psychologists, licensed psychological associates, licensed clinical social workers, licensed clinical mental health counselors (formerly licensed professional counselors), licensed marriage and family therapists, registered nurses, nurse practitioners (including psychiatric nurse practitioners), pediatricians, registered dieticians, nutritionists, registered dieticians, physicians, and physicians assistants.
  • Prior Authorization
    • Prior authorization requirements for services delivered in-person will still apply when delivered via telehealth. NC ITP telehealth services can be provided under existing prior authorizations.

See “Temporary Modifications to Attachment A” for a list of NC ITP service codes that can be billed as telehealth services, and additional coding and billing guidance.
 

Diabetes Self-Management Education (DSME)

The following are policy modifications related to DSME services:

  • Eligible Services 
    • DSME can be delivered via telehealth to new or established patients during the COVID-19 public health emergency. All DSME services delivered remotely should follow the specific requirements, standards and guidance included in the NC Medicaid Diabetes Outpatient Self-Management Education Clinical Coverage Policy 1A-24.
  •  Eligible Providers
    • The following non- practitioner providers that typically provide DSME services are eligible to deliver these services via telehealth: certified diabetes educators (CDEs), registered nurses, behaviorists who are Ed.D. prepared, and registered dieticians who are employed by physicians or entities.
    • Diabetes education services delivered via telehealth by Non practitioner providers must be billed by  one of the following eligible physician practitioners/sites: physicians, nurse practitioners, physicians’ assistants, certified nurse midwives, clinical pharmacists’ practitioners, hospital outpatient departments, local health departments, federally qualified health centers, and rural health centers. These physician practitioners/sites are also eligible to deliver DSME via telehealth directly to patients (in lieu of a non-physician practitioner noted above).

See “Temporary Modifications to Attachment A” for additional coding and billing guidance related to DSME.

Dietary Evaluation and Counseling

The following are policy modifications related to dietary evaluation and counseling services. 

  • Eligible Services 
    • Dietary evaluation and counseling services can be delivered via telehealth modalities to new or established patients during the COVID-19 public health emergency. All dietary and counseling services delivered remotely should follow the specific requirements, standards, and guidance included in the NC Division of Medical Assistance Dietary Evaluation and Counseling and Medical Lactation Services Clinical Coverage Policy 1I.
  • Eligible Providers
    • The following providers may deliver dietary evaluation and counseling services via telehealth: licensed dieticians, licensed nutritionists and registered dieticians.

See “Temporary Modifications to Attachment A” for additional coding and billing guidance related to dietary evaluation and counseling.

Medical Lactation

The following are policy modifications related to medical lactation services. 

  • Eligible Services 
    • Medical lactation services can be delivered via telehealth to new or established patients during the COVID-19 public health emergency. All medical lactation services delivered remotely should follow the specific requirements, standards and guidance included in the NC Division of Medical Assistance Dietary Evaluation and Counseling and Medical Lactation Services Clinical Coverage Policy 1I.
  • Eligible Providers
    • The following providers may deliver medical lactation services via telehealth: physicians, certified nurse midwives, nurse practitioners, physician assistants and international board-certified lactation consultants (IBCLC).

See “Temporary Modifications to Attachment A” for additional coding and billing guidance related to medical lactation.
 

Research-Based Behavioral Health (RB-BHT) Treatment for Autism Spectrum Disorder (ASD)

The following are policy modifications related to research-based treatment for autism. 

  • Eligible Services 
    • Researched-based treatment for autism spectrum disorder can be delivered via telehealth to new or established patients during the COVID-19 public health emergency. All RB-BHT ASD services delivered remotely should follow the specific requirements, standards and guidance included in the NC Medicaid Research-Based Behavioral Health Treatment for Autism Spectrum Disorder Clinical Coverage Policy 8F.
  • Eligible Providers
    • The following providers may deliver RB-BHT ASD via telehealth: 
    • Licensed Qualified Autism Service Providers (LQASP): physicians, developmental or behavioral pediatricians, licensed psychologists, licensed psychological associates, occupational therapists, speech and language therapists, licensed clinical social workers, licensed clinical mental health counselors (formerly licensed professional counselors), and licensed marriage and family therapists; or 
    • Providers of Research-Based Behavioral Health Treatment when those services are delivered by:
      • A Certified – Qualified Professional, or
      • A Technician under the supervision of a LQASP.
  • Prior authorization
    • Prior authorization requirements for RB-BHT ASD services delivered in-person will still apply when delivered via telehealth.

See “Temporary Modifications to Attachment A” for additional coding and billing guidance related to RB-BHT ASD.

Virtual Patient Communication Services

NC Medicaid has issued new guidance and codes for the delivery of virtual patient communication services.

Online Digital E/M Codes

 

  • 99421 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • 99422 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
  • 99423 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

Online digital E/M services require physician or other qualified health care professional (QHP) evaluation, assessment and management of the patient.  QHP providers are nurse practitioners, physician assistants,  certified nurse midwives, and clinical pharmacist practitioners.  These services are not for the non-evaluative electronic communication of test results, scheduling of appointments or other communication that does not include E/M. Patients initiate online digital E/M services through HIPAA-compliant, secure platforms such as electronic health record (EHR) portals, secure email or other digital application.

See “Temporary Modifications to Attachment A” for additional coding and billing guidance.
 

Interprofessional Consultations (QHP to MD)

 

  • 99446 - Interprofessional telephone/internet/electronic health records assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review.
  • 99447 - Interprofessional telephone/internet/electronic health records assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review.
  • 99448 - Interprofessional telephone/internet/electronic health records assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review.
  • 99449 - Interprofessional telephone/internet/electronic health records assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review. 

Temporary Modifications to Attachment A: Claims-Related Information

Retroactive to March 10, 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 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)

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), 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 or HCPCS code exists, then the provider(s) shall report the procedure, product or service using the appropriate unlisted procedure or service code.
Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) may bill for telehealth, telepsychiatry and select virtual patient communication services if the service follows core service billing requirements as outlined in clinical coverage policy 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics. Information concerning Virtual Communication Services provided by FQHCs and RHCs is located here: https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center

Note: Codes billable by FQHCs and RHCs are identified with a plus sign (+). 

C.1. Telemedicine, Telepsychiatry and Virtual Patient Communications

C.1.a. The following new and established patient office or other outpatient service and office and inpatient consultation codes, when provided via telemedicine or telepsychiatry, may be billed by physicians, nurse practitioners (including psychiatric), physician assistants, advanced practice midwives and clinical pharmacist practitioners. 

Codes

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

99241

99242

99243

99244

99245

99251

99252

99253

99254

99255

T1015+

C.1.b. The following online digital evaluation and management codes may be billed by physicians, physician assistants, nurse practitioners, advance practice midwives, FQHCs, FQHC Look-Alikes and RHCs.

Codes

99421+

99422+

99423+

C.1.c. The following telephonic evaluation and management and virtual patient communication codes may be billed by physicians, physician assistants, nurse practitioners and advance practice midwives.

Codes

99441

99442

99443

  G0071+

G2012

C.1.d. The following interprofessional assessment and management codes may be billed by physicians only.

Codes

99446

99447

99448

99449

C.1.e. The following psychiatric diagnostic evaluation and psychotherapy codes, when provided by telepsychiatry, may be billed by licensed clinical addiction specialists, licensed clinical mental health and professional counselors, licensed psychologists, licensed psychological associates, licensed clinical social workers, licensed marriage and family therapists, physicians, and psychiatric nurse practitioners.

 NOTE: Psychiatric diagnostic evaluation and psychotherapy codes 90792, 90833, 90836, and 90838, marked with an asterisk (*) can only be billed by licensed psychiatric prescribing providers (physicians, physician assistants and nurse practitioners) as outlined in CCP 8C Section 6.1.

Codes

90791

90792*

90832

90833*

90834

90836*

90837

90838*

90839

90840

90846

90847

90849

90853

90785

T1015-HI+

C.1.f. The following behavioral health testing and screening codes may now be billed by appropriate licensed clinicians (as outlined in CCP 8C) using telepsychiatry (real time two-way audio/video). Psychiatrists/physicians, psychiatric nurse practitioners, physician assistants, licensed psychologists and licensed psychological associates may bill the code in the table below. Please note, the qualified testing professional should be aware that many current developmental, psychological and neuropsychological tests do not have normative groups for tests administered virtually or via telehealth and, as such, test results may need to be interpreted with caution. See the following APA link for guidance: https://www.apa.org/practice/guidelines/telepsychology

Codes

96110

C.1.g. The following behavioral health testing and screening codes may now be billed by appropriate licensed clinicians (as outlined in CCP 8C) using telepsychiatry (real time two-way audio/video). Psychiatrists/physicians, licensed psychologists and licensed psychological associates may bill the codes in the table below. Please note, the qualified testing professional should be aware that many current developmental, psychological and neuropsychological tests do not have normative groups for tests administered virtually or via telehealth and, as such, test results may need to be interpreted with caution. See the following APA link for guidance: https://www.apa.org/practice/guidelines/telepsychology.

Codes

96112

96113

96116

96121

96130

96131

96132

96133

96136

96137

96138

96139

96146

 

C.1.h. The following telephone assessment and management codes may be billed by licensed clinical addiction specialists, licensed clinical addiction specialist associates, licensed mental health and professional counselors, licensed mental health and professional counselor associates, licensed psychologists, licensed psychological associates, licensed clinical social workers,  licensed clinical social worker associates, licensed marriage and family therapists, licensed marriage and family therapist associates.

Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) may bill for services provided by licensed clinical addiction specialists, licensed clinical mental health counselors, licensed psychologists, licensed psychological associates, licensed clinical social workers and licensed marriage and family therapists

Codes

98966+

98967+

98968+

C.1.i. The following inpatient professional codes (requiring real-time, two-way audio/video) when provided by telepsychiatry may be billed by licensed psychiatric prescribing providers (MD/DO Psychiatrists and PMHNP-BCs).

Codes

99231

99232

99233

99238

99230

C.2. Local Education Agencies
C.2.a. The following new and established patient codes, when provided via telehealth (real-time audio/video), may be billed by physical therapists in LEAs.
 

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

 

C.2.b. The following new and established patient codes, when provided via telehealth, may be billed by occupational therapists in LEAs.

 

Codes

Description (See 2020 CPT Code Book for Complete Details)

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

(approved for oral function and feeding only)

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.

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

C.2.c. The following new and established patient codes, when provided via telehealth, may be billed by speech language therapists in LEAs. 

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

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 (approved for oral function and feeding only)

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

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

C.2.d. The following established patient codes, when provided via telehealth, may be billed by audiologists in LEAs.

Codes

Description (See 2020 CPT Code Book for Complete Details)

92630

Auditory rehabilitation; prelingual hearing loss

92633

Auditory rehabilitation; postlingual hearing loss

C.2.e. The following new and established patient codes, when provided via telehealth, may be billed by the appropriate psychology and/or counseling professional in LEAs per clinical coverage policy 10C.

Codes

Description (See 2020 CPT Code Book for Complete Details)

90832

Psychotherapy, 30 minutes with patient

90834

Psychotherapy, 45 minutes with patient

90837

Psychotherapy, 60 minutes with patient

90847

Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment and fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments with performed), by physician or other qualified health care professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment and fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments with performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes

96130

Psychological testing evaluation by qualified health care professional, first 60 minutes

96131

Psychological testing evaluation by qualified health care professional, additional 60 minutes

C.3. CDSA Coding Guidance - the following codes, when provided via telehealth (real-time audio/video), can be billed by CDSAs
C.3.a. The following new and established patient codes, when provided via telehealth, can be billed by occupational therapists.
 

Codes

Description (See 2020 CPT Code Book for Complete Details)

92526 (feeding only)

Treatment of swallowing dysfunction and/or oral function for feeding (approved for oral function and feeding only)

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

97110

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic

97112

Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular

97116

Therapeutic procedure, one or more areas, each 15 minutes; gait training

97165

Evaluation of occupational therapy, typically 30 minutes

97166

Evaluation of occupational therapy, typically 45 minutes

97167

Evaluation of occupational therapy established plan of care, typically 60 minutes

97168

Re-evaluation of occupational therapy established plan of care, typically 30 minutes

97533

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

97535

Self-care/home management training (e.g., activities of daily living and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

97542

Wheelchair management/propulsion training, each 15 minutes

97750

Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.

97763

Management and/or training in use of orthotics (supports, braces or splints for arms, legs and/or trunk, per 15 minutes)

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.b. The following new and established patient codes, when provided via telehealth, can be billed by physical therapists.

Codes

Description (See 2020 CPT Code Book for Complete Details)

92526 (feeding only)

Treatment of swallowing dysfunction and/or oral function for feeding (approved for oral function and feeding only)

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

97110

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic

97112

Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular

97116

Therapeutic procedure, one or more areas, each 15 minutes; gait training

97162

Evaluation of physical therapy, typically 30 minutes

97163

Evaluation of physical therapy, typically 45 minutes

97164

Re-evaluation of physical therapy, typically 20 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/propulsion training, each 15 minutes

97750

Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.

97763

Management and/or training in use of orthotics (supports, braces or splints for arms, legs and/or trunk, per 15 minutes)

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.c. The following new and established patient codes, when provided via telehealth, can be billed by speech and language therapists.

Codes

Description (See 2020 CPT Code Book for Complete Details)

92507

Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual

92521

Evaluation of speech fluency

92522

Evaluation of speech sound production and expression

92523

Evaluation of speech sound production with evaluation of language comprehension.

92524

Behavioral and qualitative analysis of voice and resonance.

92526 (feeding only)

Treatment of swallowing dysfunction and/or oral function for feeding (approved for oral function and feeding only)

92630

Auditory rehabilitation; pre-lingual hearing loss

92633

Auditory rehabilitation; post-lingual hearing loss

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration by physician or other qualified healthcare professional, with interpretation and report; first 60 minutes

96113

Developmental test administration by qualified health professional with interpretation and report, additional 30 minutes

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.d. The following new and established patient codes, when provided via telehealth, can be billed by nurse practitioners (including psychiatric nurse practitioners).

Codes

Description (See 2020 CPT Code Book for Complete Details)

90832

Psychotherapy, 30 minutes with patient

90834

Psychotherapy, 45 minutes with patient

90837

Psychotherapy, 60 minutes with patient

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

99211

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are minimal. Approximately 5 minutes

99212

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are self-limited or minor. Approximately 10 minutes

99213

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are of low to moderate severity. Approximately 15 minutes

99214

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Approximately 25 minutes

99215

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Approximately 40 minutes

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.e. The following new and established patient codes, when provided via telehealth, can be provided by registered nurses who are Qualified Professionals (QPs).

Codes

Description (See 2020 CPT Code Book for Complete Details)

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.f. The following new and established patient codes, when provided via telehealth, can be billed by audiologists.

Codes

Description (See 2020 CPT Code Book for Complete Details)

92630

Auditory rehabilitation; pre-lingual hearing loss

92633

Auditory rehabilitation; post-lingual hearing loss

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.g. The following new and established patient codes, when provided via telehealth, can be provided by educational diagnosticians.

Codes

Description (See 2020 CPT Code Book for Complete Details)

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.h. The following new and established patient codes, when provided via telehealth, can be billed by licensed psychologists.

Codes

Description (See 2020 CPT Code Book for Complete Details)

90832

Psychotherapy, 30 minutes with patient

90834

Psychotherapy, 45 minutes with patient

90837

Psychotherapy, 60 minutes with patient

90846

Family psychotherapy (without the patient present)

90847

Family Psychotherapy (conjoint psychotherapy) (with patient present)

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

96116

Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgement

96121

Neurobehavioral status examination by qualified health care professional with interpretation and report, additional 60 minutes

96130

Psychological testing evaluation by qualified health care professional, first 60 minutes

96131

Psychological testing evaluation by qualified health care professional, additional 60 minutes

96132

Neuropsychological testing evaluation by qualified health care professional, first 60 minutes

96133

Neuropsychological testing evaluation by qualified health care professional, additional 60 minutes

H0031

Mental health assessment, by non-physician

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.i. The following new and established patient codes, when provided via telehealth, can be billed by licensed clinical mental health counselors (formerly licensed professional counselors), licensed psychological associates, and licensed marriage and family therapists.

Codes

Description (See 2020 CPT Code Book for Complete Details)

90832

Psychotherapy, 30 minutes with patient

90834

Psychotherapy, 45 minutes with patient

90837

Psychotherapy, 60 minutes with patient

90846

Family psychotherapy (without the patient present), 50 minutes

90847

Family Psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes

H0031

Mental health assessment, by non-physician

 

 

 

 

 

 

 

 

 

 

 

C.3.j. The following new and established patient codes, when provided via telehealth, can be billed by licensed clinical social workers.

Codes

Description (See 2020 CPT Code Book for Complete Details)

90832

Psychotherapy, 30 minutes with patient

90834

Psychotherapy, 45 minutes with patient

90837

Psychotherapy, 60 minutes with patient

90846

Family psychotherapy (without the patient present), 50 minutes

90847

Family Psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

H0031

Mental health assessment, by non-physician

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.k. The following new and established patient codes, when provided via telehealth, can be provided by nutritionists.

Codes

Description (See 2020 CPT Code Book for Complete Details)

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

97802

Medical nutrition therapy, initial assessment and intervention, individual

97803

Medical nutrition therapy, re-assessment and intervention, individual

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.l. The following new and established patient codes, when provided via telehealth, can be provided by infant, toddler and family specialists.

Codes

Description (See 2020 CPT Code Book for Complete Details)

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

H0036

Community psychiatric supportive treatment, face-to-face, per 15 minutes

H0036-HI

Community based services early children intervention professional, individual, 15 minutes

H0036-HM

Community based services paraprofessional, individual, 15 minutes

H0036-HQ

Community based services professional group 2 clients, 15 minutes

H0036-TL

Community based services, professional, 2 clients, 15 minutes

H0036-UI

Community based services paraprofessional group 2 clients, 15 minutes

T1017

Target case management- early intervention

T1023

Screening to determine the appropriateness of consideration of an individual

C.3.m. The following new and established patient codes, when provided via telehealth, can be billed by physicians.

Codes

Description (See 2020 CPT Code Book for Complete Details)

90832

Psychotherapy, 30 minutes

90834

Psychotherapy, 45 minutes

90837

Psychotherapy, 60 minutes

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

96116

Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgement

96121

Neurobehavioral status examination by qualified health care professional with interpretation and report, additional 60 minutes

96132

Neuropsychological testing evaluation by qualified health care professional, first 60 minutes

96133

Neuropsychological testing evaluation by qualified health care professional, additional 60 minutes

99201

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are self-limited or minor. Approximately 10 minutes-

99202

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are of low to moderate severity. Approximately 20 minutes

99203

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are of moderate severity. Approximately 30 minutes

99204

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are of moderate to high severity. Approximately 45 minutes

99205

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are of moderate to high severity. Approximately 60 minutes

99211

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are minimal. Approximately 5 minutes

99212

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are self-limited or minor. Approximately 10 minutes

99213

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are of low to moderate severity. Approximately 15 minutes

99214

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Approximately 25 minutes

99215

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Approximately 40 minutes

99241

Office consultation for anew or established patient. Usually presenting problem(s) are self-limited or minor. Approximately 15 minutes

99242

Office consultation for anew or established patient. Usually presenting problem(s) are of low severity. Approximately 30 minutes

99243

Office consultation for anew or established patient. Usually presenting problem(s) are of moderate severity. Approximately 40 minutes

99244

Office consultation for anew or established patient. Usually presenting problem(s) are of moderate to high severity. Approximately 60 minutes

99245

Office consultation for anew or established patient. Usually presenting problem(s) are of moderate to high severity. Approximately 80 minutes

T1023

Screening to determine appropriateness of consideration of an individual

C.3.n. The following new and established patient codes, when provided via telehealth, can be billed by physician assistants. 

Codes

Description (See 2020 CPT Code Book for Complete Details)

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

99211

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are minimal. Approximately 5 minutes

99212

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are self-limited or minor. Approximately 10 minutes

99213

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are of low to moderate severity. Approximately 15 minutes

99214

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Approximately 25 minutes

99215

Office or other outpatient visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Approximately 40 minutes

C.3.o. The following new and established patient codes, when provided via telehealth, can be provided by registered dieticians.

Codes

Description (See 2020 CPT Code Book for Complete Details)

96110

Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

96112

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; first hour

96113

Developmental test administration (including assessment of fine motor and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes

97802

Medical nutrition therapy, initial assessment and intervention, individual

97803

Medical nutrition therapy, re-assessment and intervention, individual

C.4. Diabetes Self-Management Education Coding Guidance

The following new and established patient codes, when provided via telehealth, can be billed  by the following physician practitioners: physicians, nurse practitioners, physician assistant, certified nurse midwives, clinical pharmacist practitioners (CPP), hospital outpatient departments, local health departments, federally qualified health centers/rural health clinics.  They may also bill for the DSME services provided by registered nurses, certified diabetes educators, behaviorists who are Ed. D prepared, registered dieticians who are employed by physicians or entities.

Code

Description (See 2020 CPT Code Book for Complete Details)

G0108

Diabetes outpatient self-management training services, individual, per 30 minutes

C.5. Dietary Evaluation and Counseling Coding Guidance

The following new and established patient codes, when provided via telehealth, by dieticians or nutritionists currently licensed by the N.C. Board of Dietetics Nutrition and dieticians registered with the Commission of Dietetic Registration who are employed by physicians, NPs, PAs, CNM, CPPs, hospital outpatient departments, local health departments, federally qualified health centers/rural health clinics. 

Code

Description (See 2020 CPT Code Book for Complete Details)

97802

Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.

97803

Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

C.6. Medical Lactation Coding Guidance

The following new and established patient codes, when provided via telehealth, can be billed by physicians, nurse practitioners, physician assistants, certified nurse midwives, nurse practitioners, physician assistants . The services of international board-certified lactation consultants who are employed or contracted by the physician or physician group or have a referral for a consult in another medical practice can be billed by the physician.

Code

Description (See 2020 CPT Code Book for Complete Details)

96156

Health behavior assessment, or reassessment (i.e., health-focused clinical interview, behavioral observations, clinical decision making)

96158

Health behavior intervention, individual, face-to-face; initial 30 minutes

96159

Health behavior intervention, individual, face-to-face; each additional 15 minutes

C.7. Research-Based Behavioral Health Treatment for Autism Spectrum Disorder Coding Guidance

The following new and established patient codes, when provided via telehealth, can be billed by

  • Licensed Qualified Autism Service Providers (LQASP), including: physicians; developmental or behavioral pediatricians; licensed psychologists; licensed psychological assistants; occupational therapists; speech and language pathologists; licensed clinical social workers; licensed clinical mental health counselors (formerly licensed professional counselors), and, licensed marriage and family therapists; or,
  • Providers of Research-Based Behavioral Health Treatment when those services are delivered by:
    • A Certified – Qualified Professional, or
    • A Technician under the supervision of a LQASP.
  • See CCP 8F for additional guidance regarding the delivery of these services. 

Code

Description (See 2020 CPT Code Book for Complete Details)

97151

Behavior Identification Assessment, 15 minutes (Note: Only an individual, entity or group that meets the criteria for an LQASP can provide 97151)

97152

Behavior Identification Supporting Assessment, 15 minutes

97153

Adaptive Behavior Treatment by Protocol, 15 minutes

97154

Group Adaptive Behavior Treatment by Protocol, 15 minutes

97155*

Adaptive behavior treatment with protocol modification

97156

Family Adaptive Behavior Treatment Guidance, 15 minutes

97157

Multiple-Family Group Adaptive Behavior Treatment Guidance, 15 minutes

*In administering 97155, the physician or other qualified health care professional resolves one or more problems with the protocol and may simultaneously direct a technician in administering the modified protocol while the patient is present. Physician or other qualified health care professional direction to the technician without the patient present is not reported separately.

C.8. HCPCS Codes

The following HCPCS code can be billed for the Telehealth originating site facility fee by the originating site (the site at which the beneficiary is located): Q3014. Refer to Subsection 6.3 for list of providers.

HCPCS code T1023 can be billed only by diagnostic assessment agencies for screening / evaluation to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encounter (1 unit = 1 event). T1023 (1 unit) is billed for the date that the total assessment is completed by the agency that employs the providers of service.

C.9. Revenue Codes

When the originating site is a hospital, the originating site facility fee must be billed with RC780 and Q3014.

C.10. Unlisted Procedure or Service

  • 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.
  • 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.

  • 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.

E. Billing Unit

Provider(s) shall report the appropriate code(s) used which determines the billing unit(s).

F. Place of Service

Telemedicine and telepsychiatry claims should be filed with the provider’s usual place of service code per the appropriate clinical coverage policy and not Place of Service (POS) 02 (telehealth). 

G. Copayments

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.

Additional Resources

NC Medicaid Telehealth Billing Code Summary Chart 

NC Medicaid Telehealth Resources website 

NC Medicaid COVID-19 Resources website