SPECIAL BULLETIN COVID-19 #49: Telehealth Clinical Policy Modifications - Interim Perinatal Care Guidance

Update May 11, 2020: The first bullet under "Intersection with the Pregnancy Medical Home (PMH) Program" has been modified to encourage providers to complete the PMH Pregnancy Risk Screening Form at any time when prenatal care is first established. This replaces the former "at any point in the first trimester."

Update May 1, 2020: Added billing guidance for providing antepartum or postpartum care via a telehealth visit with a simultaneous home visit made by an appropriately-trained delegated staff person. Added table to section C.3. Revised F. Place of Service text 

Important Notes to Bulletin #49:

• SPECIAL BULLETIN COVID-19 #49: Telehealth Clinical Policy Modifications – Interim Perinatal Care Guidance replaces in its entirety SPECIAL BULLETIN COVID-19 #42: Telehealth Clinical Policy Modifications – Postpartum Care.
• Additional perinatal guidance may be released in the future, which would replace this bulletin.
• Please note the change to billing guidance for postpartum care visits: Postpartum care visits can be billed separately OR as part of a pregnancy package code. 

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 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the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.

In an effort to reduce exposure and help deliver non-urgent care to beneficiaries in their homes, NC Medicaid is now allowing eligible providers to provide antepartum and postpartum care via telemedicine. Providers are responsible for determining when it is clinically appropriate to conduct such visits via telemedicine or in-person. Guidance from the NC Pregnancy Medical Home on standards of care is forthcoming.

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

Perinatal Care Modifications

Eligible Providers and Services

• Eligible providers, including physicians, nurse practitioners, physician assistants, certified nurse midwives may conduct antepartum and postpartum care visits via telemedicine with new or established patients during the state of emergency; these visits may not be conducted via virtual patient communication (e.g., telephone conversations).
• Providers can conduct any antepartum or postpartum visits via telemedicine, including a patient’s first antepartum visit, as is clinically appropriate. 
• Refer to Clinical Coverage Policy 1E-6 – Pregnancy Medical Home for additional guidance regarding antepartum and postpartum care visits.

Billing Guidance

• Pregnancy care can be billed two different ways -- as part of a pregnancy package code or as separate visits. Whether these services are billed as part of a pregnancy package code or separately, they can be conducted via telemedicine but must be appended with GT and CR modifiers to identity that one or more antepartum and/or postpartum visits were conducted via telemedicine.
• Providers are not required to bill antepartum or postpartum care visits separate from a delivery when such a visit is conducted via telemedicine, if that visit would have been covered in-person as part of a pregnancy package code.

Intersection with the Pregnancy Medical Home (PMH) Program

• NC Medicaid has temporarily relaxed requirements within Clinical Coverage Policy 1E-6 – Pregnancy Medical Home to encourage providers to complete the PMH Pregnancy Risk Screening Form at any time when prenatal care is first established. Enrolled PMH providers may complete the PMH Pregnancy Risk Screening Form via an in-person visit, telemedicine visit, telephone call, or online patient portal communication. The practice should bill the related incentive HCPCS code (S0280) as they normally would.
• Enrolled PMH providers should bill the postpartum incentive using HCPCS code S0281 as they normally would if a postpartum visit is completed via telemedicine. 
• GT and CR modifiers are not required for the S0280 or S0281 HCPCS codes.
• For more guidance on the use of PMH codes, see the clinical coverage policy 1E-6: /documents/files/1e6/download
• Please look to clinical guidance and standards of maternity care provided through telehealth from the Pregnancy Medical Home leadership through Community Care North Carolina: https://www.communitycarenc.org/what-we-do/clinical-programs/pregnancy-…

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

UPDATE: Billing guidance for providing antepartum or postpartum care via a telehealth visit with a simultaneous home visit made by an appropriately-trained delegated staff person

• During this state of emergency, eligible providers may conduct antepartum or postpartum care via a telemedicine visit with a simultaneous home visit made by an appropriately-trained delegated staff person. Any vaccines, lab tests or other additional services administered during the home visit may be billed as they normally would be for an office visit.
• Billing guidance when the provider is billing the pregnancy global package codes:
  • To reflect the additional cost of the delegated staff person attending the patient’s home, eligible providers may bill a telemedicine originating site facility fee (HCPCS code Q3014) for each telemedicine visit conducted with simultaneous home visit. The originating site fee may be billed in addition to the pregnancy global package codes. 
  • To be reimbursed for the originating site facility fee for this care model, all of the following requirements must be met for each home visit:
    • The assistance delivered in the home must be given by an appropriately-trained delegated staff person.
    • The fee must be billed on the same day that the home visit is conducted.
    • HCPCS code Q3014 must be appended with the GT and CR modifiers and billed with a place of service “12” to designate that the originating site was the home.
    • The antepartum or postpartum telehealth visit must be covered under the pregnancy or global package code for the pregnancy. 
  • Please see Clinical Coverage Policy No: 1H Telemedicine and Telepsychiatry for more information about originating site facility fees.
• Billing guidance when the provider is not billing the pregnancy global package codes:
  • Providers should bill the home visit codes as outlined in Special Bulletin COVID-19 #78: Telehealth Clinical Policy Modifications – Telemedicine with Supporting Home Visit. Providers should not bill an originating site facility fee.

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 perinatal care codes, when provided via telemedicine to a new or established patient, may be billed by physicians, nurse practitioners, physician assistants, and certified nurse midwives.

Note: FQHCs, FQHC Look-Alikes and RHCs that bill T1015 for perinatal services rendered by core service providers may continue to do so when those services are provided via telemedicine.

C.2 The following Pregnancy Medical Home incentive codes may be billed after the specific services associated with each code are provided, consistent with the guidance above.

C.3 The following originating site facility fee code may be billed by an eligible provider for each telemedicine visit conducted with a simultaneous home visit attended by a designated staff person. 

Note: The incentive codes in section C.2. do not require GT or CR modifiers.

D. Modifiers

• Provider(s) shall follow applicable modifier guidelines. These modifiers should be applied to any perinatal codes, including pregnancy package codes, if at least one visit was conducted via telemedicine (audio-visual communication).  These modifiers do not need to be applied to the codes in table C.2.
• 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 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). The following must be billed with Place of Service 12 to designate that the originating site was the home: 1) an antepartum or postpartum telehealth visit; 2) an originating site facility fee code (Q3014) for telemedicine visits with a simultaneous home visit.

G. Copayments

• For Medicaid, refer to Medicaid State Plan, Attachment 4.18-A, page 1.
• For NC Health Choice, refer to G.S. 108A-70.21(d).

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.
• 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

Contact

NCTracks Contact Center: 800-688-6696