NC Medicaid has temporarily modified its Telemedicine and Telepsychiatry Clinical Coverage Policy to better enable the delivery of remote care to Medicaid beneficiaries. These 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the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.
This Bulletin temporarily adds coverage for providers to help their patients engage in Self-Measured Blood Pressure Monitoring (“SMBPM”) and to monitor blood pressure readings that patients submit, thereby allowing enhanced management of blood pressure without the need for an in-person visit.
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.”
Self-Measured Blood Pressure Monitoring (SMBPM) Policy Modifications
The following are policy modifications related to self-measured blood pressure monitoring:
- Eligible Services and Devices
- SMBPM is a patient’s regular use of a personal blood pressure monitoring device to assess and record blood pressure across different points in time outside of a clinical setting, typically at home.
- SMBPM is available to new and established patients.
- There are two codes that eligible providers may bill for SMBPM services (99473, 99474) and specific rules and restrictions apply to the use of these codes (guidance included in C.1.a of “Temporary Modifications to Attachment A” listed below).
- The SMBPM device must be validated for clinical accuracy whenever safely possible. Special Bulletin COVID-19 #29 released on March 31, 2020, added coverage for automatic blood pressure monitors through Durable Medical Equipment providers and home health agencies. Eligible blood pressure monitoring devices include, but are not limited to, such devices.
- Eligible Providers: Physicians, nurse practitioners, physician assistants, and certified nurse midwives are eligible to bill for SMBPM services. Additionally, FQHCs, FQHC Lookalikes and RHCs are eligible to bill for SMBPM services under fee-for-service reimbursement.
- Prior Authorization and In-Person Examinations: Patients are not required to obtain prior authorization or have an initial in-person examination prior to receiving SMBPM services.
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 or when the policy modification is rescinded, NC Medicaid is temporarily modifying Attachment A. 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.1. Self-Measured Blood Pressure Monitoring (SMBPM) Services
C.1.a. The following new codes may be billed by physicians, nurse practitioners, physician assistants, certified nurse midwives; additionally, FQHCs, FQHC Lookalikes and RHCs can bill under fee-for-service reimbursement.
Description (See 2020 CPT Code Book for Complete Details)
Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration.
Separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient.
SMBPM Coding Guidance
- Providers may bill code 99473 only once per patient, per device. Code 99473 may be performed remotely.
- During the COVID-19 emergency, providers have the option to bill code 99474 weekly as an alternative to monthly, as appropriate based on the patient’s needs. If providers elect to bill code 99474 on a weekly cycle, a minimum of 12 readings in each week is required.
- Providers may not bill code 99474 for both weekly and monthly review of the same patient’s blood pressure but can bill weekly up to four times in a month period if medically necessary.
- Providers should not bill online digital evaluation and management codes (99421-99423) for exclusively reviewing SMBPM data; they should instead bill 99474.
- No more than one provider may bill code 99473 for the same patient. No more than one practice may bill code 99474 for the same patient in the same month.
- More guidance is available at https://www.ama-assn.org/delivering-care/hypertension/what-you-need-know-about-self-measured-blood-pressure-monitoring
Provider(s) shall follow applicable modifier guidelines.
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).
- For Medicaid, refer to Medicaid State Plan, Attachment 4.18-A, page 1, located at https://medicaid.ncdhhs.gov/document/state-plan-under-title-xix-social-….
- For NC Health Choice, refer to G.S. 108A-70.21(d), located at http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter….
Provider(s) shall bill their usual and customary charges. For a schedule of rates, refer to https://medicaid.ncdhhs.gov/providers/fee-schedules.
- NC Medicaid Telehealth Billing Code Summary Chart
- NC Medicaid Telehealth Resources website
- NC Medicaid COVID-19 Resources website
Author: GDIT, (800) 688-6696