SPECIAL BULLETIN COVID-19 #66: Telehealth and Virtual Patient Communications Clinical Policy Modifications - Well Child Visits

Friday, April 24, 2020

NC Medicaid and Health Choice 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the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded. 

NC Medicaid is temporarily adding telemedicine coverage for providers to conduct Well Child Visits with patients to ensure the provision of comprehensive and preventive health care services for children under age 21. Providers are encouraged to continue providing well child visits, immunizations and or preventive care during the pandemic. For additional information on the delivery of Well Child Visits during the pandemic, see guidance from the American Academy of Pediatrics.

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.

Well Child Visit Modifications

The following are policy modifications related to Well Child Visits.

For Children under 24 Months

NC Medicaid continues to recommend in-person visits to deliver the vast majority of Well Child services to children under 24 months of age; a limited set of services may be delivered via telemedicine during the state of emergency, if necessary. 

Eligible Providers and Services

  • Eligible providers, including physicians, nurse practitioners, and physician assistants should continue to provide Well Child Visit services in-person to the extent possible during the state of emergency. These services are generally not covered when delivered via telemedicine to children under 24 months, except in extenuating circumstances in which case the justification for a telemedicine visit must be well-documented in the patient’s chart. 
  • FQHCs, FQHC Look-alikes, and RHCs may deliver Well Child services via telemedicine and will be reimbursed on a fee-for-service basis, as they would if the services were delivered in-person. Claims should be submitted in the same manner as pre-COVID except adding CR modifier to distinguish between pre-COVID claims.
  • If circumstances prevent a provider from delivering Well Child services in-person, a select set of Well Child Services may be provided via telemedicine by eligible providers to new and established patients, including:
    • Developmental screenings;
    • Emotional/behavioral screenings;
    • Preventive medicine/individual counseling;
    • Anticipatory guidance;
    • Vaccine counseling. Note: The provider may provide vaccine counseling by telemedicine, and then administer the vaccine at a later date (e.g., via curb-side vaccine services). The immunization administration code should be billed at the time of vaccine administration by the provider.
  • Providers should continue to report codes for in-person Well Child visits using the appropriate CPT codes along with immunization and other procedural codes. 
  • In an extenuating circumstance in which a child under 24 months receives a preventive medicine visit via telemedicine, he/she should have an in-person Well Child visit as soon as possible, when the provider and family mutually agree it is safe.
    • For the initial telemedicine visit, providers should the bill the appropriate preventive medicine service code with the appropriate modifiers described in Attachment A.  
    • For the following face to face visit, providers should bill the appropriate evaluation and management code with the CR modifier to identify that remaining components of the preventative medicine visit have been completed. See Attachment A for eligible E/M codes.
  • Maternal depression screens may be billed to the child’s Medicaid as CPT 96161. NC Medicaid will reimburse providers for up to 4 maternal depression risk screens administered to mothers during the infant’s first year postpartum.

For Children 24 Months and Older

NC Medicaid recommends that providers consider telemedicine to deliver a broad range of Well Child Services for children 24 months and older, as is clinically appropriate. 

Eligible Providers and Services

  • Eligible providers, including physicians, nurse practitioners, and physician assistant may provide Well Child Visit services via telemedicine with new and established patients during the state of emergency. 
  • FQHCs, FQHC Look-alikes, and RHCs may deliver Well Child services via telemedicine and will be reimbursed on a fee-for-service basis, as they would if the services were delivered in-person. Claims should be submitted in the same manner as pre-COVID except adding CR modifier to distinguish between pre-COVID claims.
  • Providers should use their clinical judgement to determine what components of Well Child services are appropriate to be performed during the telemedicine visit.  
  • Providers are encouraged to continue providing immunizations to their patients during the COVID-19 pandemic. The provider may provide vaccine counseling by telemedicine, and then administer the vaccine at a later date (e.g., via curb-side vaccine services). The immunization administration code would be billed at the time of vaccine administration by the provider.
  • Any member who receives a preventive medicine visit via telemedicine should have an in-person Well Child visit as soon as possible, when the provider and family mutually agree it is safe.
    • For the initial telemedicine visit, providers should the bill the appropriate preventive medicine service code with the appropriate modifiers described in Attachment A.  
    • For the following face to face visit, providers should bill the appropriate evaluation and management code with the CR modifier to identify that remaining components of the preventative medicine visit have been completed. See Attachment A for eligible E/M codes.

Prior Authorization and In-Person Examinations

Patients are not required to obtain prior authorization or have an initial in-person examination prior to receiving Well Child Visit 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 and NC Health Choice.

A. Claim Type

  • Professional (CMS-1500/837P transaction)
  • Institutional (UB-04/837I 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 Well Child Visit codes, when provided via telemedicine to a new or established patient under 24 months of age, may be billed by physicians, nurse practitioners and physician assistants.

Children Under 24 Months: Eligible Telemedicine Service Codes

Codes

Modifiers

(NC Medicaid)

Modifiers

(NC Health Choice)

Description (See 2020 CPT Code Book for Complete Details)

Preventive Medicine Services

May only be provided to children under 24 months in extenuating circumstances, in which case the justification for a telemedicine visit must be well-documented in the patient’s chart.

99381

EP-GT-CR

TJ-GT-CR

Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient, early childhood (younger than 1 year)

99382

EP-GT-CR

TJ-GT-CR

Initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient, early childhood (age 1 through 4 years)

99391

EP-GT-CR

TJ-GT-CR

Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient, infant (younger than 1 year)

99392

EP-GT-CR

TJ-GT-CR

Periodic comprehensive preventative medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient, early childhood (1 through 4 years)

Evaluation and Management Codes to be Used for Follow-Up In-Person Visits

99211

CR

CR

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

CR

CR

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; 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

CR

CR

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; 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 of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99214

CR

CR

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; 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 of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

99215

CR

CR

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; 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 of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

Developmental Screening

96110

EP-GT-CR

TJ-GT-CR

Developmental screening (e.g. developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

Emotional/Behavioral Screening

96127

EP-GT-CR

TJ-GT-CR

Brief emotional/behavioral assessment (e.g. depression inventory, attention-deficit/hyperactivity disorder (ADHD) scale), with scoring and documentation, per standardized instrument

Health Risk Assessment

96160

EP-GT-CR

TJ-GT-CR

Administration of patient-focused health risk assessment instrument (e.g. health hazard appraisal) with scoring and documentation, per standardized instrument

96161

EP-GT-CR

Not Applicable

Administration of caregiver-focused health risk assessment instrument (e.g. depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

Note: Maternal depression screens may be billed to the child’s Medicaid as CPT 96161. NC Medicaid will reimburse providers for up to 4 maternal depression risk screens administered to mothers during the infant’s first year postpartum.

Immunization Administration

90460

EP-CR

TJ-CR

Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered

Note: Providers should code when the vaccine is administered. Vaccine counseling may occur via telemedicine at any time prior to the administration of the vaccine. If vaccine counseling is provided in-person, the 90460 code should be billed as usual. If vaccine counseling as described by this code is not provided, use the appropriate vaccine administration code(s).

C.2 The following Well Child Visit codes, when provided via telemedicine to a new or established patient 24 months and older, may be billed by physicians, nurse practitioners, and physician assistants.

Children 24 Months and Older: Eligible Telemedicine Service Codes

Codes

Modifiers

(Medicaid)

Modifiers

(NC Health Choice)

Description (See 2020 CPT Code Book for Complete Details)

Preventive Medicine Services

99382

EP-GT-CR

TJ-GT-CR

Initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient, early childhood (age 1 through 4 years)

99383

EP-GT-CR

TJ-GT-CR

Initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient, late childhood (age 5 through 11 years)

99384

EP-GT-CR

TJ-GT-CR

Initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient, adolescent (age 12 through 17 years)

99385

EP-GT-CR

*through age 21

TJ-GT-CR

*through age 18

Initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient, 18 through 39 years

99392

EP-GT-CR

TJ-GT-CR

Periodic comprehensive preventative medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient, early childhood (1 through 4 years)

99393

EP-GT-CR

TJ-GT-CR

Periodic comprehensive preventative medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient, late childhood (5 through 11 years)

99394

EP-GT-CR

TJ-GT-CR

Periodic comprehensive preventative medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient, adolescent (12 through 17 years)

99395

EP-GT-CR

*through age 21

TJ-GT-CR

*through age 18

Periodic comprehensive preventative medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient, 18 through 39 years

Evaluation and Management Codes to be Used for Follow-Up In-Person Visits

99211

CR

CR

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

CR

CR

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; 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

CR

CR

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; 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 of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99214

CR

CR

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; 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 of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

99215

CR

CR

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; 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 of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

Developmental Screening

96110

EP-GT-CR

TJ-GT-CR

Developmental screening (e.g. developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

Emotional/Behavioral Screening

96127

EP-GT-CR

TJ-GT-CR

Brief emotional/behavioral assessment (e.g. depression inventory, attention-deficit/hyperactivity disorder (ADHD) scale), with scoring and documentation, per standardized instrument

Health Risk Assessment

96160

EP-GT-CR

TJ-GT-CR

Administration of patient-focused health risk assessment instrument (e.g. health hazard appraisal) with scoring and documentation, per standardized instrument

96161

EP-GT-CR

TJ-GT-CR

Administration of caregiver-focused health risk assessment instrument (e.g. depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

Immunization Administration

90460

EP-CR

TJ-CR

Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered

Note: Providers should code when the vaccine is administered. Vaccine counseling may occur via telemedicine at any time prior to the administration of the vaccine. If vaccine counseling is provided in-person, the 90460 code should be billed as usual. If vaccine counseling as described by this code is not provided, use the appropriate vaccine administration code(s).

D. Modifiers

Provider(s) shall follow applicable modifier guidelines.

  • Modifier EP (Health Check) or TJ (Health Choice) must be appended to each CPT or HCPCS code for all visits, except follow-up in-person visits in which E/M codes should be billed only with the CR modifier. 
  • 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 codes listed in this policy, including any visits conducted via telemedicine and any follow-up in-person visits.

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). 

G. Copayments

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 COVID-19 Resources website

ICD-10-CM Official Coding and Reporting Guidelines April 1, 2020 through September 30, 2020

AMA Fact Sheet: Reporting Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) Laboratory Testing

Contact

NCTracks Contact Center: 800-688-6696