Medi-Cal NewsFlash: COVID-19 Guidance for Telehealth and Virtual/Telephonic Communications

If you have Medi-Cal you can get telehealth services more than privately insured patients. but how many have broadband internet?

COVID-19 Guidance for Telehealth and Virtual/Telephonic Communications

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  Section I: Current Medi-Cal Policy for Enrolled Medi-Cal Providers: As outlined in the Medi-Cal Provider Manual (Medicine: Telehealth) and/or posted to the Medi-Cal Rates Information Page:
• Traditional telehealth modalities, i.e., synchronous two-way interactive, audio-visual communication and asynchronous store and forward, inclusive of e-consults
• Other virtual/telephonic communication modalities
• Section II: Current Medi-Cal Policy for FQHCs, RHCs, Tribal 638 Clinics: As outlined in various sections of the Medi-Cal Provider Manual (Federally Qualified Health Centers/Rural Health Clinics, and Indian Health Services Memorandum of Agreement 638 Clinics), and/or posted to the Medi-Cal Rates Information Page:
• Traditional telehealth modalities, i.e., synchronous two-way interactive, audio-visual communication and asynchronous store and forward.
• Other virtual/telephonic communication modalities
• Section III: DHCS’ Section 1135 Waiver Request Related to the Novel Coronavirus Disease (COVID-19), Submitted March 16, 2020
• Additional flexibilities and options relative to traditional telehealth modalities, i.e., synchronous two-way, audio-visual communication and asynchronous store and forward, inclusive of e-consults
• Additional flexibilities and options relative to other virtual/telephonic communication modalities

The majority of the Guidance has to do with arcane billing rulings and procedures such as CPT codes. The relative items include the need for telecommunications due to quarantine and isolation concerns.

SECTION I: CURRENT MEDI-CAL POLICY FOR ENROLLED MEDI-CAL PROVIDERS

Traditional Telehealth - Overview
For enrolled Medi-Cal providers, including but not limited to physicians, nurses, mental health practitioners, substance use disorder practitioners, dentists, etc., the below policy applies. Please note that this does not apply to FQHCs, RHCs, and Tribal 638 Clinics, for which the policy is described below.

• Medi-Cal providers may bill DHCS or their managed care plan as appropriate for any covered Medi-Cal benefits or services using the appropriate procedure codes, i.e., Current Procedural Terminology (CPT) or Health Care Procedures Coding System (HCPS) codes, as defined by the American Medical Association (AMA) in the most current version of the billing manual that are appropriate to be provided via a telehealth modality. The CPT or HCPCS code(s) must be billed using Place of Service Code “02” as well as the appropriate telehealth modifier, as follows:
• Synchronous, interactive audio and telecommunications systems: Modifier 95
• Asynchronous store and forward telecommunications systems: Modifier GQ
Please note that DHCS will use the telehealth modifiers to identify that the Medi-Cal covered benefit or service was provided via a telehealth modality for tracking and reporting purposes relative to COVID-19. As a result, DHCS requests that all providers ensure the appropriate modifier is included on all submitted claims.

Originating Site and Transmission Fee
The originating site facility fee is reimbursable only to the originating site when billed with HCPCS code Q3014 (telehealth originating site facility fee). Transmission costs incurred from providing telehealth services via audio/video communication is reimbursable when billed with HCPCS code T1014 (telehealth transmission, per minute, professional services bill separately).

Restrictions for billing originating site fee and transmission costs are as follows:

• HCPCS code Q3014 – Billable by originating site; once per day; same patient, same provider.
• HCPCS code T1014 – Originating site and distant site; maximum of 90 minutes per day (1 unit = 1 minute), same patient, same provider
• Originating site fees and transmission costs are not available for telephonic services.

SECTION III: DHCS’ SECTION 1135 WAIVER REQUEST RELATED TO COVID-19

Overview
DHCS has requested additional flexibilities in terms of the available modalities for delivering Medi-Cal covered benefits and services, as part of its Section 1135 Waiver. DHCS recognizes that in addition to traditional telehealth/telemedicine modalities (i.e., synchronous two-way interactive, audio-visual communication, and/or asynchronous store and forward/e-consults), as outlined in existing Medi-Cal coverage policy, there are extraordinary circumstances under which both face-to-face visits as well as traditional telehealth modalities are not an option.

Under these limited and extraordinary instances (such as COVID-19), DHCS recognizes the need for Medi-Cal providers – including but not limited to physicians, nurses, mental health practitioners, substances use disorder practitioners, FQHCs, RHCs, and Tribal 638 Clinics – to utilize other methods such as telehealth and virtual/telephonic communication to provide medically necessary health care services.

Unless otherwise agreed to by the MCP and provider, DHCS and Managed Care Plans (MCPs) must reimburse Medi-Cal providers at the same rate, whether a service is provided in-person or through telehealth, if the service is the same regardless of the modality of delivery, as determined by the provider’s description of the service on the claim. DHCS and Managed Care Plans (MCPs) must provide the same amount of reimbursement for a service rendered via telephone or virtual communication, as they would if the service is rendered via video, provided the modality by which the service is rendered (telephone versus video) is medically appropriate for the member.

Other Virtual/Telephonic Communications
Medi-Cal providers, – including but not limited to physicians, nurses, mental health practitioners, substances use disorder practitioners, FQHCs, RHCs, and Tribal 638 Clinics, will provide and bill for visits consistent with in person visits using the appropriate and regular CPT or HCPCS codes that would correspond to the visit being done in-person, and include POS 02 and Modifier 95. The virtual/telephonic visit must meet all requirements of the billed CPT or HCPCS code and must meet the following conditions:

• There are documented circumstances involved that prevent the visit from being conducted face-to-face, such as the patient is quarantined at home, local or state guidelines direct that the patient remain at home, the patient lives remotely and does not have access to the internet or the internet does not support Health Insurance Portability and Accountability Act (HIPAA) compliance, etc.
• The treating health care practitioner is intending for the virtual/telephone encounter to take the place of a face-to-face visit, and documents this in the patient’s medical record.
• The treating health care practitioner believes that the Medi-Cal covered service or benefit being provided are medically necessary.
• The Medi-Cal covered service or benefit being provided is clinically appropriate to be delivered via virtual/telephonic communication, and does not require the physical presence of the patient.
• The treating health care practitioner satisfies all of the procedural and technical components of the Medi-Cal covered service or benefit being provided except for the face-to-face component, which would include but not be limited to:
• a detailed patient history
• a complete description of what Medi-Cal covered benefit or service was provided
• an assessment/examination of the issues being raised by the patient
• medical decision-making by the health care practitioner of low, moderate, or high complexity, as applicable, which should include items such as pertinent diagnosis(es) at the conclusion of the visit, and any recommendations for diagnostic studies, follow-up or treatments, including prescriptions

Sufficient documentation must be in the medical record that satisfies the requirements of the specific CPT or HCPCs code utilized. The provider can then bill DHCS or the managed care plan as appropriate. 

NewsFlash: COVID-19 Guidance for Telehealth and Virtual/Telephonic Communications: