SPECIAL BULLETIN COVID-19 #77: Telehealth and Virtual Patient Communications Clinical Policy Modifications – End Stage Renal Disease Services

Friday, May 1, 2020

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earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.

This Bulletin temporarily enables eligible providers to deliver end stage renal disease services via telemedicine in light of social distancing measures that may prevent in-person visits.    

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.

Definitions

  • Telemedicine is the use of two-way real-time interactive audio and video to provide care and services when participants are in different physical locations.

End Stage Renal Disease Services Modifications

The following are policy modifications:

  • End stage rental disease (ESRD) services, including monthly/daily capitation services and training, may now be conducted via telemedicine (two-way real-time, interactive audio and video) with both new and established patients, as appropriate.
  • While it is understood that providers should have at least one “hands on visit” per month to complete the required clinical examination of the vascular access site, this service can be provided via telemedicine.
  • Eligible providers include physicians, nurse practitioners, and physician assistants.
  • Patients are not required to obtain prior authorization prior to receiving 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)

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 ESRD service codes, when provided via telemedicine to a new or established patient, may be billed by physicians, nurse practitioners and physician assistants.

Code Modifiers (NC Medicaid) Modifiers (NC Health Choice) Description (See 2020 CPT Code Book for Complete Details)

Monthly Capitation Services

90951

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents with 4 or more face-to-face visits by a physician or other qualified health care professional per month.

90952

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents with 2-3 face-to-face visits by a physician or other qualified health care professional per month.

90953

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents with 1 face-to-face visit by a physician or other qualified health care professional per month.

90954

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents, with 4 or more face-to-face visits by a physician or other qualified health care professional per month.

90955

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents with 2-3 face-to-face visits by a physician or other qualified health care professional per month.

90956

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents, with 1 face-to-face visit by a physician or other qualified health care professional per month.

90957

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents with 4 or more face-to-face visits by a physician or other qualified health care professional per month.

90958

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents with 2-3 face-to-face visits by a physician or other qualified health care professional per month.

90959

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents with 1 face-to-face visit by a physician or other qualified health care professional per month.

90960

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month.

90961

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2-3 face-to-face visits by a physician or other qualified health care professional per month.

90962

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face visit by a physician or other qualified health care professional per month.

90963

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents.

90964

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents.

90965

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents.

90966

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older.

Daily Capitation Services

90967

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services for dialysis less than a full month of service, per day, for patients younger than 2 years old.

90968

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services for dialysis less than a full month of service, per day, for patients 2-11 years of age.

90969

GT-CR

GT-CR

End-Stage renal disease (ESRD) related services for dialysis less than a full month of service, per day, for patients 12-19 years of age.

90970

GT-CR

Not eligible

End-Stage renal disease (ESRD) related services for dialysis less than a full month of service, per day, for patients 20 years of age and older.

Training Services

90989

GT-CR

GT-CR

Dialysis training, patient, including helper where applicable, any mode, completed course.

90993

GT-CR

GT-CR

Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session.

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

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). 

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

Contact

NCTracks Contact Center: 800-688-6696