SPECIAL BULLETIN COVID-19 #86: Telehealth and Virtual Patient Communications Clinical Policy Modifications - Family Planning Services for MAFDN Beneficiaries

Monday, May 11, 2020

NC Medicaid has temporarily modified its Telemedicine and Telepsychiatry Clinical Coverage Policy to better enable the delivery of remote care to Medicaid (including NC Medicaid Be Smart Family Planning Medicaid program - MAFDN) 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the earlier of the cancellation of the North Carolina state of emergency declaration or when the policy modification is rescinded.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 enabling eligible providers to deliver family planning services to NC Medicaid Be Smart Family Planning Medicaid program (MAFDN) eligible beneficiaries via telemedicine or virtual patient communication (telephone call, only) in light of social distancing measures that may prevent in-person visits.

NC Medicaid has already issued guidance (see Special Bulletin COVID-19 #34) that enables providers to deliver a broad range of medical and family planning services via telemedicine or virtual patient communication (telephone call, only) to traditional Medicaid beneficiaries. Select family planning services in the NC Medicaid Clinical Coverage Policy 1-E7 that NC Medicaid has enabled to be delivered via telemedicine or virtual patient communication (telephone call, only) during the state of emergency for traditional Medicaid beneficiaries are also available to MAFDN beneficiaries, and are included in this Bulletin. Note, at this time Medicaid has not authorized adult annual exams through telemedicine or virtual patient communications.

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. 
  • Virtual Patient Communication is the use of technologies other than video to enable remote evaluation and consultation support between a provider and a patient or a provider and another provider. Covered virtual patient communication services include telephone conversations (audio only); virtual portal communications (e.g., secure messaging); and store and forward (e.g., transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).

Family Planning Services for MAFDN Beneficiaries 

The following are policy modifications: 

  • Eligible providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives may deliver family planning services via telemedicine (two-way real-time, audio and visual) or virtual patient communication (telephone call, only) to MAFDN-eligible beneficiaries. 
    • Telemedicine services are available to both new and established patients.
    • Virtual patient communication (telephone call, only) services are only available to established patients.
  • Both new and established MAFDN-eligible beneficiaries may receive family planning services without an annual exam during the state of emergency (see Special Bulletin COVID-19 #54). Therefore, a new MAFDN-eligible beneficiary will have their first family planning visit in-person or via telemedicine, and an annual exam is not required.
    • Since the annual exam requirement is being waived during the state of emergency, providers may submit claims without a patient’s annual exam date.  
  • Each telemedicine or virtual patient communication family planning encounter will count as one of a beneficiary’s allotted six inter-periodic visits, per 365 days.
  • 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.A The following office or other outpatient service codes, when provided via telemedicine to a new or established MAFDN-eligible beneficiary, may be billed by physicians, nurse practitioners, physician assistants, and certified nurse midwives.

Code

Description (See 2020 CPT Code Book for Complete Details)

99201

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are self-limited or minor. Approximately 10 minutes.

99202

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are of low to moderate severity. Approximately 20 minutes.

99203

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are of moderate severity. Approximately 30 minutes.

99204

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are of moderate to high severity. Approximately 45 minutes.

99205

Office or other outpatient visit for evaluation and management of a new patient. Usually, the problem(s) are of moderate to high severity. Approximately 60 minutes.

99211

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

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

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

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

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.

99241

Office consultation for a new or established patient, which requires these 3 components:

  • A problem-focused history;
  • A problem-focused examination; and,
  • 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, 15 minutes are spent face-to-face with the patient and/or family.

99242

Office consultation for a new or established patient, which requires these 3 components:

  • An expanded problem focused history;
  • An expanded problem focused examination; and,
  • 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 of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

99243

Office consultation for a new or established patient, which requires these 3 components:

  • A detailed history;
  • A detailed examination; and,
  • 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 moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

99244

Office consultation for a new or established patient, which requires these 3 components:

  • A comprehensive history;
  • A comprehensive examination; and,
  • 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, 60 minutes are spent face-to-face with the patient and/or family.

C.1.B The following telephonic evaluation and management codes, when provided via virtual patient communication (telephone call, only) to an established MAFDN-eligible beneficiary, may be billed by physicians, nurse practitioners, physician assistants, and certified nurse midwives.

Code

Description (See 2020 CPT Code Book for Complete Details)

99441

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion   

99442

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

99443

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

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. This modifier is not appropriate for services performed telephonically.
  • Modifier CR (catastrophe/disaster related) must be appended to all claims for CPT codes listed in this policy. The use of modifier CR will bypass time limitations (7 day and 24 hour) and editing on these codes related to COVID-19.
  • Modifier FP must be appended to all claims for CPT codes listed in this policy to designate family planning services.

E. Billing Unit

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

F. Place of Service

Telemedicine and virtual patient communication 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/

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.

Since the annual exam requirement is being waived during the state of emergency, providers may submit claims without a patient’s annual exam date.  

Additional Resources

Contact

NCTracks Contact Center: 800-688-6696