SPECIAL BULLETIN COVID-19 #41: Telehealth Clinical Policy Modifications – Optometry Services

Thursday, April 9, 2020

Background and General Guidance

NC Medicaid has temporarily modified its Telemedicine and Telepsychiatry Clinical Coverage Policy to better enable the delivery of remote care to Medicaid and Health Choice 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the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded. When the temporary modifications end, all face-to-face service requirements will resume.

For additional information, refer to Bulletin #34: Telehealth Clinical Policy Modifications – Definitions, Eligible Providers, General Services and Codes.

Specific guidance related to billing and coding is detailed in the section “Temporary Modifications to Attachment A.”

Optometry Policy Modifications

Eligible Providers and Services - Optometrists may now bill for the following services when delivered remotely:

  • Office or Other Outpatient Services delivered via telehealth between an optometrist and an established patient
  • Virtual Patient Communications between an optometrist and an established patient
  • Interprofessional Consultations conducted via telephone/internet/electronic health records between an optometrist and a qualified health professional    

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

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)

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)

C.1. The following office or other outpatient services codes, when provided via telehealth to an established patient, may be billed by optometrists. 

Codes

Description (See 2020 CPT Code Book for Complete Details)

99211*

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services

99212*

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these key components: A problem focused history; A problem focused examination; or Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family

99213*

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these key components: An expanded problem focused history; An expanded problem focused examination; or, Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family

99214*

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these key components: A detailed history; A detailed examination; or, Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family

99215*

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these key components: A comprehensive history; A comprehensive examination; or, Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family

*A GT modifier must be appended to the CPT 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.

C.2 The following virtual patient communication codes, when provided to an established patient, may be billed by optometrists. 

Codes

Description (See 2020 CPT Code Book for Complete Details)

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 nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

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        

99441  

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor 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 evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor 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 evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;21-30 minutes of medical discussion

C.3 The following interprofessional consultation codes may be billed by optometrists.

Codes

Description (See 2020 CPT Code Book for Complete Details)

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

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 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/providers/fee-schedules/optometry-fee-schedule. 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.
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 

Author: GDIT, (800) 688-6696