SPECIAL BULLETIN COVID-19 #46: Behavioral Health Service Flexibilities

Author: NCTracks: (800) 688-6696; NCTracksProvider@nctracks.com

Background and General Guidance

Effective April 16, 2020, NC Medicaid, in partnership with the DHHS Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMHDDSAS), is temporarily modifying its Behavioral Health and Intellectual and Developmental Disability Clinical Coverage Policies to better enable the delivery of care to NC Medicaid, NC Health Choice and State-funded individuals in response to the COVID-19 Pandemic.

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the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.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 prior service requirements will resume.

During the North Carolina declared state of emergency, services must continue to be provided at an intensity and quality that meet the needs of the individual, consistent with the individual’s goals and the intended outcomes of the service. In addition, the service must be provided by staff at a ratio (as relevant) and with the expertise and scope necessary to meet the needs of each individual.

Throughout this bulletin, “telehealth” means two-way real-time interactive audio and video to provide care and services when participants are in different physical locations. Telehealth does not include telephonic provision of services; when telephonic provision is permitted, it is specifically noted below.

Providers must ensure that services outlined in this bulletin can be safely and effectively delivered using telehealth or telephonic modalities.
Providers must consider an individual’s behavioral, physical and cognitive abilities to participate in services provided using telehealth or telephonic interventions.
The individual’s safety must be carefully considered for the complexity of the services provided. In situations where caregivers or facilitators are necessary to assist with the delivery of telehealth or telephonic services, their ability to assist and their safety should also be considered when the individual needs physical assistance.
Delivery of services using telehealth or telephonic interventions 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 relevant Practice Acts and Licensing Board rules.

Supervision must continue to be provided per the applicable Clinical Coverage Policy but may be provided virtually as indicated below; virtual supervision includes real-time interactive two-way audio and video, as well as telephonic modes of communication. Supervision should be increased accordingly when provider staff do not receive relevant trainings that have been temporarily waived. Please note, staff trainings are only waived (as indicated below) if there are not opportunities to receive the specific training(s) virtually.

The following tables outline the allowed service flexibilities during this declared state of emergency.

Table 1: Behavioral Health Emergency Flexibilities by Policy

Procedure Code	Clinical Coverage Policy	Emergency Flexibilities
Enhanced Behavioral Health Service
H2011	8A Mobile Crisis Management	Waive prior authorization after the initial unmanaged 32 units of service. (For state-funded recipients, check with your LME-MCO to determine if prior authorization is waived). Waive 24 hours as the maximum length of service. Waive staff training requirements within 90 days of employment, if unable to be obtained during the state of emergency. Waive 80 percent of the service must be provided face-to-face. Allow for supervision by any licensed professional on the team or employed by the agency if Team Lead is sick or unavailable.
T1023	8A Diagnostic Assessment	Waive prior authorization for additional units beyond one unmanaged Diagnostic Assessment per state fiscal year. (For state-funded recipients, check with your LME-MCO to determine if Prior Authorization is waived). Diagnostic Assessment can be provided via telehealth per NC Medicaid Clinical Coverage Policy 1-H.
H2022	8A Intensive In-Home	Waive reauthorization. (For state-funded recipients, check with your LME-MCO to determine if reauthorization is waived). Waive staff training requirements within 30 and 90 day of employment, if unable to be obtained during the state of emergency. Waive the two hour per day minimum service provision and reduce to one hour per day in order to bill. Waive requirement that staff must be dedicated to the team. Waive requirements that 60 percent of contacts should be face to face and 60 percent of staff time should be spent outside of facility. Waive team to family ratio of 1:12. Allow for supervision by any licensed professional on the team or employed by the provider agency, within scope and training, if Team Lead is sick or unavailable. Allow supervision by Team Lead, or designee as noted above, to occur virtually.
H2033	8A Multisystemic Therapy	Waive reauthorization. (For state-funded recipients, check with your LME-MCO to determine if reauthorization is waived). Waive staff introductory and quarterly training requirements if unable to be obtained during the state of emergency. Waive requirement that staff must be dedicated to the team. Waive minimum monthly contacts of 12 in the first month and six contacts in the second and third month must be met unless individual or family member becomes ill during month and cannot receive services. Waive the three to five-month maximum duration of service. Waive requirements that 50 percent of face-to-face contact with beneficiary and family and 60 percent of staff time should occur outside of facility. Waive maximum of 480 units per three months. Allow supervision by another master’s level qualified professional (QP) employed by the provider agency if team lead is sick or unavailable.
H2015 HT, HO/HF/HN/U1/HM	8A-6 Community Support Team	Waive reauthorization. (For state-funded recipients, check with your LME-MCO to determine if reauthorization is waived). Waive requirement that staff must be dedicated to the team. Waive requirement that associate licensed professional team lead be fully licensed within 30 months. Waive maximum of eight units for first and last 30-day period for individuals transitioning to and from other services and allow for 40 units of service overlap. Waive Comprehensive Clinical Assessment for beyond six months of treatment. Waive staff to beneficiary ratio of 1:12. Waive monitoring of delivery of service by Team Leader. Waive staff training requirements within 30 and 90 days of employment, if unable to be obtained during the state of emergency. Waive requirement that 75 percent of the service must be delivered face-to-face and outside of agency. Allow functional assessments and crisis interventions to be completed via telehealth or telephonic modalities, as clinically appropriate. Allow team meetings to occur virtually.
H0040	8A-1 Assertive Community Treatment	Waive reauthorization. (For state-funded recipients, check with your LME-MCO to determine if reauthorization is waived). Waive requirement that staff must be dedicated to the team. Waive staff to beneficiary ratio of 1:8 for small teams and 1:9 for medium and large teams. Waive requirement that team must demonstrate fidelity to the latest tool for Measurement of ACT (TMACT) model of care. Waive staff training requirements within 120 days of employment, if unable to be obtained during the state of emergency. Waive medium rate of service frequency and median rate of service intensity. Allow any agency employed licensed staff, to provide supervision within scope if team lead is sick or unavailable. Allow Associate licensed professional to have more than 30 months to become fully licensed. Allow supervision to occur virtually.
H2017	8A Psychosocial Rehabilitation	Waive initial prior authorization and reauthorization (For state-funded recipients, check with your LME-MCO to determine that initial prior authorization and reauthorization is waived). Waive requirement for a minimum of five hours per day, five days a week of service availability. Service must be available a minimum of 10 hours per week. Waive staff ratio of 1:8 only if provided via telehealth or telephonic modalities. Allow service to be provided outside of the facility via telehealth, telephonically, or in-person, including in the person’s residence.
H2012HA	8A Child and Adolescent Day Treatment	Waive reauthorization. (For state-funded recipients, check with your LME-MCO to determine if reauthorization is waived). Waive requirement that staff must be dedicated to the team. Waive requirement that a maximum of 25 percent of treatment services may be provided outside of the day treatment facility. Waive staff to beneficiary ratio if provided outside of the facility. Waive minimum of three hours of service per day. Waive requirements for staff training within 30 and 90 days of employment and follow up and ongoing continuing education requirements for fidelity of clinical models, if unable to be obtained during the state of emergency. Allow for supervision by any licensed professional, within scope, employed by the provider agency if team lead is sick or unavailable. Allow service when school is not in operation. Allow service to be provided outside of the facility via telehealth, telephonically, or in-person, including in the person’s residence.
H0035	8A Partial Hospitalization	Waive reauthorization. (For state-funded recipients check with your LME-MCO to determine if reauthorization is waived). Waive requirement of minimum service availability of four hours a day five days per week; but, must provide 10 hours of treatment per week in order to bill. Allow service to be provided outside of the facility via telehealth, telephonically, or in-person, including in the person’s residence
H0015	8A Substance Abuse Intensive Outpatient Program	Waive reauthorization after the initial 30-day pass through. (For state-funded recipients, check with your LME- MCO to determine if reauthorization is waived). Waive the required minimum service availability of three hours per day three days per week; but, must provide 1.5 hours of treatment per day, three days per week to bill. Waive beneficiary to staff ratio if provided outside of the facility. Waive requirement that the CCS or LCAS be on-site 50 percent of the hours open; but, must be available virtually. Waive Urine Drug Screening requirements. Waive requirement for family counseling if the family is unavailable, sick or unwilling to participate in telehealth or telephonic interventions. Allow service to be provided outside of the facility via telehealth, telephonically, or in-person, including in the person’s residence.
H2035	8A Substance Abuse Comprehensive Outpatient Treatment	Waive reauthorization after the initial 60-day pass through. (For state-funded recipients, check with your LME-MCO to determine if reauthorization is waived). Waive the required for minimum service availability of four hours per day, five days per week; but, must provide two hours per day, five days per week to bill. Waive beneficiary to staff ratio if provided outside of the facility. Waive requirement that CCS or LCAS must be on-site but must be available virtually a minimum of 90 percent of the hours the service is in operation. Waive Urine Drug Screening requirements. Waive requirement for family counseling if family is unavailable, sick or unwilling to participate in telehealth or telephonic interventions. Allow service to be provided outside of the facility via telehealth, telephonically, or in-person, including in the person’s residence
H0014	8A Ambulatory Detoxification	Waive initial authorization and reauthorization. (For state-funded recipients, check with your LME-MCO to determine if initial authorization and reauthorization are waived). Allow supervision of LCAS or CCS to occur virtually.
H0012	8A Substance Abuse Non-Medical Community Residential Treatment	Waive initial authorization and reauthorization. (For state-funded recipients, check with your LME-MCO to determine if initial authorization and reauthorization are waived). Waive the per person service maximum of 30 days of treatment in 12 months. Allow LCAS and CCS to provide services via telehealth or telephonically interventions in lieu of being provided in-person at the facility. Allow supervision of QP, AP, and paraprofessionals to occur virtually.
H0013	8A Substance Abuse Medically Monitored Community Residential Treatment	Waive initial authorization and reauthorization. (For state-funded recipients, check with your LME-MCO to determine if initial authorization and reauthorization are waived). Waive the per person service maximum of no more than 30 days of treatment in 12 months. Allow LCAS and CCS to provide services via telehealth or telephonically in lieu of being provided in-person at the facility. Allow supervision of QP, AP and paraprofessionals to occur virtually.
H0010	8A Non-Hospital Medical Detoxification	Waive initial authorization and reauthorization (For state-funded recipients, check with your LME-MCO to determine if initial authorization and reauthorization are waived). Waive the per person service maximum of no more than 30 days of treatment in 12 months. Allow LCAS and CCS to provide services via telehealth or telephonically in lieu of being provided in-person at the facility. Allow physician assessments to be completed by telehealth. Allow supervision of QP, AP, and paraprofessionals to occur virtually.
H0020	8A Outpatient Opioid Treatment	Waive initial authorization and reauthorization. (For state-funded recipients, check with your LME-MCO to determine if initial authorization and reauthorization are waived). Allow for up to 28 units to be billed in one day to allow for take home dosing for clinically appropriate individuals for up to 28 days. See Medicaid Special Bulletin COVID-19 #34, Section C.1. for information on telehealth and other CPTcodes that are often billed in conjunction with H0020
H0038; H0038HQ	8G Peer Support Services: Peer Support Services (PSS)	Waive initial authorization and reauthorization. (For state-funded recipients, check with your LME-MCO to determine if initial authorization and reauthorization are waived). Waive staff to beneficiary ratio. Waive requirement that telephone time be 20 percent or less of total service time per individual per year. Waive staff training requirements unable to be obtained during the state of emergency within 30 and 90 days of employment. Allow supervision to occur virtually. Allow for Peer Support Services Program Supervisor to fulfill 90-day face-to-face contact through telehealth or telephonically. **Peers must still be North Carolina Certified Peer Support Specialists.
H0019	8D-2 Residential Treatment Services Level III	Waive staff training requirements if unable to be obtained during the state of emergency, except for sex offender specific training. Allow sex offender specific training to occur virtually. Allow QP, social worker, psychologist or psychiatrist to provide treatment, services and consultation via telehealth and telephonically, as clinically indicated and based on level of expertise, instead of providing on-site at the facility.
H2020	8D-2 Residential Treatment Services Level I and II – Family Type-	Waive reauthorization. (For state-funded recipients, check with your LME-MCO to determine that reauthorization is waived). Waive staff training requirements unable to be performed during the state of emergency, except sex offender specific training. Allow sex offender training to occur virtually. Allow QP, licensed professional, psychologist, psychiatrist to provide treatment and consultation via telehealth and/or telephonically, as clinically indicated and based on level of expertise, instead of providing on-site at the facility. All supervision and daily structure services must be provided in-person by the appropriate staff.
H2020	Residential Treatment Services 8D-2 Level II –- Program Type	Waive reauthorization. (For state-funded recipients, check with your LME-MCO to determine that reauthorization is waived). Waive staff training requirements if unable to be obtained during the state of emergency, except for sex offender specific training. Allow Sex Offender training to occur virtually. Allow QP, social worker, psychologist or psychiatrist to provide treatment, services, and consultation via telehealth and telephonically, as clinically indicated and based on level of expertise, instead of providing on-site at the facility.
H0019	8D-2 Residential Treatment Services Level IV	Allow social worker, psychologist or psychiatrist to provide services via telehealth instead of providing them in-person at facility. Waive requirement that parent, and legal guardian must participate in rehabilitation plan development and implementation if unavailable due to illness. Waive opportunity for individual inclusion in community activities. Waive staff training requirement if unable to be obtained during the state of emergency except for sex offender specific training. Allow sex offender training to occur virtually.
RC 0911	8D-1 Psychiatric Residential Treatment Facility for Children under the Age of 21	Allow psychiatrist to provide services via telehealth instead of providing on-site at the facility. Allow licensed therapist(s) to provide services via telehealth instead of providing on-site at the facility.
RC183	8D-1 and 8D-2Therapeutic Leave for Psychiatric Residential Treatment Facilities for Children under the Age of 21 Residential Treatment Services Levels II-IV	Allow an increase of Therapeutic Leave days from 45 days to 90 days.
RC 183	8E Therapeutic Leave for Nursing Facilities and Intermediate Care for the Mentally Retarded (ICF-MR)	Allow an increase of Therapeutic Leave days from 45 days to 90 days.
S9484	8A Professional Treatment Services in Facility-Based Crisis Program	Waive per person maximum of 30 days of treatment per calendar year.
S9484 HA	8A-2 Facility-Based Crisis Services for Children and Adolescents	Waive maximum of 30 days of treatment per calendar year Waive staff training requirements if unable to be obtained during the state of emergency. Allow psychiatric evaluation to be completed via telehealth instead of on-site at the facility and billed separately. Allow behavioral assessment to be completed via telehealth by the psychologist.
H2036	8A Medically Supervised or ADATC Detoxification Crisis Stabilization	Waive reauthorization. (For state-funded recipients check with your LME-MCO to determine reauthorization is waived). Waive maximum of 30-days of treatment within 12 months.
97151, 97152, 97153, 97154, 97155, 97156, 97157	8F Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD)	Waive reauthorization authorization. (This service is not covered by State funds through DMH/DD/SAS).
90846, 90847, 90849, 90853, 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 96110, 96112, 96113, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146	8C Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers	Waive initial and reauthorization. (For state-funded recipients check with your LME-MCO to determine if initial and reauthorization is waived).

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 two-way real-time 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.
Detailed guidance on modifiers by procedure code is included in the table below.

Table 2: Behavioral Health Service Flexibilities Modifier Guidance

Procedure Code	Clinical Coverage Policy	Modifier Guidance
H2011	8A Mobile Crisis Management	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
T1023	8A Diagnostic Assessment	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H2022	8A Intensive In-Home	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H2033	8A Multisystemic Therapy	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H2015 HT, HO/HF/HN/U1/HM	8A-6 Community Support Team	No additional modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H0040	8A-1 Assertive Community Treatment	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H2017	8A Psychosocial Rehabilitation	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H2012 HA	8A Child and Adolescent Day Treatment	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H0035	8A Partial Hospitalization	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H0015	8A Substance Abuse Intensive Outpatient Program	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H2035	8A Substance Abuse Comprehensive Outpatient Treatment	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.
H0014	8A Ambulatory Detoxification	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H0012	8A Substance Abuse Non-Medical Community Residential Treatment	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H0013	8A Substance Abuse Medically Monitored Community Residential Treatment	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H0010	8A Non-Hospital Medical Detoxification	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H0020	8A Outpatient Opioid Treatment	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H0038; H0038HQ	8G Peer Support Services: Peer Support Services (PSS)	No additional modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply
H0019	8D-2 Residential Treatment Services Level III	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H2020	8D-2 Residential Treatment Services Level II – Family Type-	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H2020	Residential Treatment Services 8D-2 Level II –- Program Type	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H0019	8D-2 Residential Treatment Services Level IV	No additional modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
RC 0911	8D-1 Psychiatric Residential Treatment Facility for Children under the Age of 21	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
RC183	8D-1 and 8D-2 Therapeutic Leave for Psychiatric Residential Treatment Facilities for Children under the Age of 21 Residential Treatment Services Levels II-IV	Modifier CR for days in excess of 60 days or beyond 15 consecutive days.
RC 183	8E Therapeutic Leave for Nursing Facilities and Intermediate Care for the Mentally Retarded (ICF-MR)	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
S9484	8A Professional Treatment Services in Facility-Based Crisis Program	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
S9484 HA	8A-2 Facility-Based Crisis Services for Children and Adolescents	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
H2036	8A Medically Supervised or ADATC Detoxification Crisis Stabilization	No modifier when done per established policy. Modifier CR when using any of the above temporary flexibilities/waivers.
97151, 97152, 97153, 97154, 97155, 97156, 97157	8F Research Based Behavioral Health Treatment for Autism Spectrum Disorder	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply
90846, 90847, 90849, 90853, 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 96110, 96112, 96113, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146	8C Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers	No modifier when done per established policy. Modifier GT when done via two-way, real time, audio and visual communication. Modifier CR when using any of the above temporary flexibilities/waivers. Use GT and CR modifiers concurrently if both apply.

Billing Unit

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

Place of Service

Telemedicine and telepsychiatry claims related to COVID-19 shall be filed with the provider’s usual place of service for fee-for-service claims submitted to NCTracks. Claims submissions to LME-MCOs will follow the guidance of the LME-MCO.

Additional Resources

NC Medicaid Telehealth Billing Code Summary Chart: /covid-19/ncmedicaid-telehealth-billing-code-summary/download
NC Medicaid Telehealth Resources website: https://medicaid.ncdhhs.gov/about-us/covid-19-guidance-and-resources/providers/covid-19-telehealth
NC Medicaid COVID-19 Resources website: http://www.medicaid.ncdhhs.gov/coronavirus