SPECIAL BULLETIN COVID-19 #67: Telehealth and Virtual Patient Communications Clinical Policy Modifications - Outpatient Respiratory Therapy

NC Medicaid has temporarily modified its Telemedicine and Telepsychiatry Clinical Coverage Policy to better enable the delivery of remote care to Medicaid and NC HealthChoice 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the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.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 eliminated the restriction that teletherapy services cannot be conducted via “video cell phone interactions.” These services can now be delivered via any HIPAA-compliant, secure technology with audio and video capabilities, including (but not limited to) smart phones, tablets and computers.

In addition, the Office of Civil Rights (OCR) at Health and Human Services (HHS) recently issued guidance noting that “covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.”

NC Medicaid will continue to evaluate telehealth policies and 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.

Outpatient Specialized Therapy Services – Respiratory Therapy

The following are temporary policy modifications related to outpatient respiratory therapy services:

Teletherapy, Eligible Providers, and Technology Requirements

Outpatient respiratory therapy providers may deliver select treatment services via teletherapy to established patients. Teletherapy refers to the use of two-way real-time interactive audio and video to provide and support health care when participants are in different physical locations. Audio-only interactions are not considered teletherapy.

Standard of Teletherapy Care

Respiratory Therapists must ensure that the services can safely and effectively be delivered via teletherapy in alignment with NC Medicaid Clinical Coverage Policies 10A, Outpatient Specialized Therapies, and 10D, Respiratory Therapy Services by Independent Practitioner Provider. Therapists must consider a client’s behavioral, physical, and cognitive abilities to participate in services provided via teletherapy.
The patient’s safety must be carefully considered for the complexity of the services provided. In addition, in situations in which a caregiver or facilitator is necessary to assist with the delivery of the teletherapy, their ability to assist and their safety should be considered as well.
Delivery of respiratory therapy services via teletherapy 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 Practice Act and Licensing Board rules. Respiratory therapists are responsible for determining which services are safe and appropriate to provide via teletherapy and which services should be provided in-person.
Respiratory therapy services may only be delivered via teletherapy to patients who already have the required respiratory equipment set up in their home.

Prior Authorization

Prior authorization (PA) requirements for respiratory therapy services provided through the Independent Practitioner Provider (IPP) program were suspended effective retroactively to March 1, 2020. This includes respiratory therapy services provided via teletherapy. However, providers are encouraged to obtain PA if it is reasonable to do so and won’t delay the provision of medically necessary respiratory therapy services. Either way, providers must maintain documentation of medical necessity and all records per Clinical Coverage Policy 10D, Respiratory Therapy Services by Independent Practitioner Provider. All claims are subject to audit.

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 respiratory therapy to Medicaid and NC HealthChoice 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)

Provider(s) shall report the most specific billing code that accurately and completely describes the procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS) and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for the code description, as it is no longer documented in the policy.

C.1. Outpatient Respiratory Therapy: The following established patient treatment codes, when provided via teletherapy, may be billed by respiratory therapists when the required equipment is already set up in the patient’s home.

Codes	Description (See 2020 CPT Code Book for Complete Details)
94010	Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation
94060	Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration
94150	Vital capacity, total (separate procedure)
94375	Respiratory flow volume loop
94664	Demonstration and/or evaluation of patient utilization of an aerosol generator nebulizer, metered dose inhaler or IPPB device
94760	Noninvasive ear or pulse oximetry for oxygen saturation; single determination
99503	Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)
99504	Home visit for mechanical ventilation care

CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in effect at the time of service.

HCPCS: The provider(s) shall refer to and comply with the Instructions for Use of HCPCS National Level II Codes, Unlisted Procedure or Service and Special Report as documented in the current HCPCS edition in effect at the time of service.

D. Modifiers

Provider(s) shall follow applicable modifier guidelines.

Modifier GT must be appended to the CPT code to indicate that a service was 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

Teletherapy claims should be submitted 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, located at https://medicaid.ncdhhs.gov/.

For NC Health Choice refer to G.S. 108A-70.21(d), located at http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_108A/GS_108A-70.21.html.

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.