SPECIAL BULLETIN COVID-19 #64: Telehealth and Virtual Patient Communications Clinical Policy Modifications - Health and Behavior Intervention Visits Provided by Local Health Departments

Friday, April 24, 2020

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earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.

NC Medicaid has temporarily enabled licensed clinical social workers at Local Health Departments to conduct Health and Behavior Intervention visits for pregnant and postpartum women who have serious psychosocial needs via telemedicine. Local health departments can bill for a variety of other medical and behavioral services provided by an MD, NP, PA, CNM, or appropriate Behavioral Health personnel when delivered via telehealth or virtual patient communications, as outlined in various NC Medicaid Special Bulletins (#34, 35, 36, 43, 48 and 49) regarding Telehealth Clinical Policy Modifications that have been instituted in light of COVID-19.

NC Medicaid will continue to evaluate telemedicine 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.” All claims are subject to audit.

Health and Behavior Intervention Visit Modifications

The following are policy modifications related to Health and Behavior Intervention Visits:

  • Eligible Services and Providers
    • Eligible providers may conduct health and behavior intervention visits with new or established high-risk pregnant and postpartum patients via telemedicine (two-way real-time, interactive audio and video). Health and behavior intervention visits include intense, focused counseling such as individualized problem-solving, priority setting, instruction, and action planning to effect behavior modification or environmental change.
    • Eligible providers include local health departments whereby the service is rendered via telemedicine by a licensed clinical social worker.
    • See Clinical Coverage Policy No: 1M-3: Health and Behavior Intervention for additional guidance about the delivery of these services and a specific list of conditions which qualify a patient as appropriate to receive such care
  • Prior Authorization and In-Person Examinations
    • Patients are not required to obtain prior authorization or have an initial in-person examination prior to receiving Health and Intervention services via telemedicine.

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.

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 Health and Behavior Intervention codes may be billed when provided via telemedicine to a new or established patient by a local health department and rendered by a licensed clinical social worker.

Additional Billing Guidance:

Health and Behavior Intervention is reimbursed for the first 30 minutes of service using CPT code 96158.  Each additional 15 minutes is reimbursed using CPT code 96159.  CPT code 96159 can only be billed after CPT 96158 has been billed first.

Total reimbursable time per day cannot exceed 60 total minutes of service. Eleven hours of Health and Behavior intervention services is allowed per pregnancy and postpartum. Claims for additional units will be considered for reimbursement through the adjustment process only when conditions of coverage are met, and documentation supports medical necessity.

Health and Behavior Intervention must be billed per date 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.

Modifier CR (catastrophe/disaster related) must be appended to all claims for CPT codes listed in this policy.

E. Billing Unit

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

F. Place of Service

Telehealth 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

For Medicaid, refer to Medicaid State Plan, Attachment 4.18-A, page 1,

H. Reimbursement

Provider(s) shall bill their usual and customary charges based on posted rate 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

Contact

NCTracks Contact Center: 800-688-6696