SPECIAL BULLETIN COVID-19 #78: Telehealth and Virtual Patient Communications Clinical Policy Modifications – Hybrid Telemedicine with Supporting Home Visit

Friday, May 1, 2020

Update (May 8, 2020)

  • Bulletin #78 includes information that Local Health Department (LHDs), Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes and Rural Health Clinics (RHCs) may use, as outlined in “Telemedicine with Supporting Home Visit” below, hybrid telemedicine with supporting home visit model when the telemedicine visit is rendered by an eligible provider. 
  • Section “C. Coding Guidance” includes instructions that providers should choose the most appropriate code based on the complexity of the services provided.

NC Medicaid has temporarily modified its Telemedicine and Telepsychiatry Clinical Coverage Policy to better enable the delivery of remote care to Medicaid and NC 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the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.

During this state of emergency, eligible providers may temporarily receive reimbursement for a telemedicine visit with a simultaneous home visit made by an appropriately trained, delegated staff person.

Reimbursement for this care model is limited to established patients. A telemedicine with supporting home visit may be used for a range of scenarios including (but not limited to) chronic disease management, well child services and perinatal care. 

  • Chronic Disease Management: Providers must use the home visit codes in this Bulletin with appropriate modifiers.
  • Well Child Services: Providers must use the home visit codes in this Bulletin with appropriate modifiers in place of the Well Child visit codes.
  • Perinatal Care: 

Under this care model, the supporting delegated staff person may perform vaccinations in the home, subject to compliance with all applicable requirements for vaccinations (e.g., it is within delegated staff person’s scope of practice to administer vaccinations) and may conduct other tests or screenings, as appropriate. 

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.

Definition

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. 

Telemedicine with Supporting Home Visit 

The following are policy modifications: 

  • Eligible providers to perform the telemedicine visit include physicians, nurse practitioners, physician assistants and certified nurse midwives. The assisting care team member performing the home visit should be an appropriately trained delegated staff person. 
  • Providers must bill home visit evaluation and management service codes with modifiers as outlined in Attachment A. 
  • Local Health Departments, FQHCs, FQHC-Lookalikes and RHCs may also utilize this hybrid telemedicine with supporting home visit model when the telemedicine visit is rendered by an eligible provider.
    • Local Health Departments may bill the home visit codes listed in Attachment A, Table C.1 below.  
    • FQHCs, FQHC-Lookalikes and RHCs may bill the home visit codes listed in Attachment A, Table C.1 for Well Child hybrid telemedicine with supporting home visits, only; 
    • FQHCs, FQHC-Lookalikes and RHCs may bill their core service code (T1015) and an originating site facility fee (Q3014) for non-Well Child hybrid telemedicine with supporting home visits to reflect the additional cost of the delegated staff person attending the patient’s home. To be reimbursed for the originating site facility fee, 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 core service code (T1015) must be billed separately from the originating site facility fee code (Q3014).
  • Patients are not required to obtain prior authorization prior to receiving these 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 Coding Instructions for Non-FQHC/RHC Providers (including Local Health Departments):

Providers should bill the following home visit evaluation and management codes for established patients, when provided by an eligible provider via telemedicine with an appropriately-trained delegated staff person simultaneously supporting the visit in the home, and should append the indicated modifiers.

Home Visit Code

Modifiers (Well Child)

Modifiers

(non-Well Child)

Description (See 2020 CPT Code Book for Complete Details)

NC Medicaid

NC Health Choice

99347

EP-GT-CR

TJ-GT-CR

GT-CR

Home visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • A problem focused interval history;
  • A problem focused examination; and
  • Straightforward medical decision making.

Presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient/family.

99348

EP-GT-CR

TJ-GT-CR

GT-CR

Home visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • An expanded problem focused interval history;
  • An expanded problem focused examination; and
  • Medical decision making of low complexity.

Presenting problem(s) are low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient/family.

99349

EP-GT-CR

TJ-GT-CR

GT-CR

Home visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • A detailed interval history;
  • A detailed examination; and
  • Medical decision making of moderate complexity.

Presenting problem(s) are low to moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient/family.

99350

EP-GT-CR

TJ-GT-CR

GT-CR

Home visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • A comprehensive interval history;
  • A comprehensive examination; and
  • Medical decision making of moderate to high complexity.

Presenting problem(s) are low to moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient/family.

Billing Guidance 

  • Providers should choose the most appropriate code based on the complexity of the services provided. If time is used as a determining factor, providers should choose the code that corresponds with the length of the telemedicine visit provided by the eligible provider (not the length of the home visit performed by the delegated staff person). 
  • To receive reimbursement for any home visit during the state of emergency that is conducted without a simultaneous telemedicine visit, providers should bill the appropriate home visit codes without the above modifiers. 
  • Well Child services only: For any additional Well Child services conducted as part of the home visit (including, but not limited to, vaccination) providers should add modifiers CR and EP + EP or TJ (as appropriate) following the billing guidance set out in Bulletin #66. 
  • For other vaccinations, tests or screenings conducted in the home that are not covered by the Well Child service codes, providers should bill as they would if they were conducted at the office (i.e., without modifiers).

C.2 Coding Instructions for FQHC, FQHC-Lookalikes and RHCs

C.2.a. Well Child hybrid telemedicine with supporting home visits: Providers should bill the following home visit evaluation and management codes for established patients, when provided by an eligible provider via telemedicine with an appropriately trained delegated staff person simultaneously supporting the visit in the home, and should append the indicated modifiers.

Home Visit Code

Modifiers (Well Child)

Description (See 2020 CPT Code Book for Complete Details)

NC Medicaid

NC Health Choice

99347

EP-GT-CR

TJ-GT-CR

Home visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • A problem focused interval history;
  • A problem focused examination; and
  • Straightforward medical decision making.

Presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient/family.

99348

EP-GT-CR

TJ-GT-CR

Home visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • An expanded problem focused interval history;
  • An expanded problem focused examination; and
  • Medical decision making of low complexity.

Presenting problem(s) are low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient/family.

99349

EP-GT-CR

TJ-GT-CR

Home visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • A detailed interval history;
  • A detailed examination; and
  • Medical decision making of moderate complexity.

Presenting problem(s) are low to moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient/family.

99350

EP-GT-CR

TJ-GT-CR

Home visit for the evaluation and management of an established patient, which requires at least two of these three key components:

  • A comprehensive interval history;
  • A comprehensive examination; and
  • Medical decision making of moderate to high complexity.

Presenting problem(s) are low to moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient/family.

 

Billing Guidance

  • Providers should choose the most appropriate code based on the complexity of the services provided. If time is used as a determining factor, providers should choose the code that corresponds with the length of the telemedicine visit provided by the eligible provider (not the length of the home visit performed by the delegated staff person). 
  • To receive reimbursement for any home visit during the state of emergency that is conducted without a simultaneous telemedicine visit, providers should bill the appropriate home visit codes without the above modifiers. 
  • Well Child services only: For any additional Well Child services conducted as part of the home visit (including, but not limited to, vaccination) providers should add modifiers CR and EP + EP or TJ (as appropriate) following the billing guidance set out in Bulletin #66. 
  • For other vaccinations, tests or screenings conducted in the home that are not covered by the Well Child service codes, providers should bill as they would if they were conducted at the office (i.e., without modifiers).

C.2.b Non-Well Child hybrid telemedicine with supporting home visits: Providers may bill the following originating site facility fee (in addition to the T1015 core service code) for established patients, when provided by an eligible provider via telemedicine with an appropriately-trained delegated staff person simultaneously supporting the visit in the home, and should append the indicated modifiers.

Codes

Modifiers (All Services)

Description

Q3014

GT + CR

Originating site facility fee code

T1015

GT + CR

Clinic visit/encounter, all-inclusive

Note: Q3014 and T1015 must be billed separately.

D. Modifiers

Provider(s) shall follow applicable modifier guidelines for a telehealth visit with supporting home visit.

  • 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 when telemedicine is combined with a supporting home visit.
  • For Well Child visits conducted via telehealth with a supporting home visit, Modifier EP (Health Check) or TJ (Health Choice) must be appended to each CPT code in addition to modifiers GT and CR, to indicate that the visit was a Well Child visit. All usual requirements for a Well Child telehealth visit must be met. 

E. Billing Unit

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

F. Place of Service

Due to the uniqueness of the home visiting care model, claims for telemedicine with supporting home visit should be filed with Place of Service (POS) 12 (home). 

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 Telehealth Billing Code Summary Chart

NC Medicaid Telehealth Resources website 

NC Medicaid COVID-19 Resources website 

Contact

NCTracks Contact Center: 800-688-6696