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MEDICAID MEMO
Updates to Telemedicine Coverage

TO: All Physicians, Nurse Practitioners, Clinical Psychologists, Clinical Nurse Specialists, Licensed Clinical Social Workers, Licensed Professional Counselors, Marriage and Family Therapists, Behavioral Health Services Providers, Nurse Midwives, Hospitals, Skilled Nursing Facilities, Intermediate Care Facilities, Renal Units, Health Department Clinics, Federally Qualified Health Centers, Rural Health Clinics, Community Services Boards, Substance Abuse Treatment Practitioner, Residential Treatment Centers-C, Local Education Agencies, School Psychologists and Managed Care Organizations Participating in the Virginia Medical Assistance Program.


FROM: Cynthia B. Jones, Director
            Department of Medical Assistance Services (DMAS)
MEMO:  Special
DATE:    May 13, 2014


SUBJECT: Updates to Telemedicine Coverage

The purpose of this memorandum is to update providers about telemedicine coverage by the Department of Medical Assistance Services (DMAS). DMAS last issued a memorandum on telemedicine coverage in September 2009.

This memorandum includes information on the expansion of providers allowed to provide services via telemedicine to physicians located outside of Virginia, including enrollment and billing requirements and an expansion of the services for which telemedicine may be utilized. Expanded services include radiology and radiology-related procedures as specified in Attachment A and Attachment B. Attachment A. includes additional provider groups who may bill DMAS as an “originating” site (procedure code Q3014) when the member is located at their site during the telemedicine encounter. The effective date of DMAS coverage for radiology and radiology related services under the column heading “In-State DMAS Enrolled Providers” and for services under the column heading “Out-of- State DMAS Enrolled Physicians” on Attachment A is April 1, 2014. Other services have been covered historically for in-state providers.


BACKGROUND ON DMAS COVERAGE OF TELEMEDICINE:


Telemedicine is the real-time or near real-time two-way transfer of medical data and information using an interactive audio/video connection for the purposes of medical diagnosis and treatment. The Medicaid member is located with a provider at the originating site, while the “remote” provider renders services via the audio/video connection. DMAS has covered telemedicine on a limited, statewide basis since July 2003.

Consistent with guidance from the Centers for Medicare & Medicaid Services, DMAS considers telemedicine as a cost-effective alternative for delivering covered services to the Medicaid and FAMIS populations.

The following are DMAS objectives for reimbursing providers for services delivered via telemedicine:

  • Improved access to health care services,
  • Improved member compliance with treatment plans,
  • Medical services rendered at an earlier stage of disease, thereby improving long-term patient outcomes, and
  • Reduced DMAS costs for covered services such as hospitalization and transportation.

The majority of Medicaid members are enrolled with a Managed Care Organization (MCO) under contract to DMAS. In order to be reimbursed for services using telemedicine that are provided to MCO enrolled individuals, providers must follow their respective contract with the MCO. The MCO may utilize different service authorization, billing, and reimbursement guidelines than those described for individuals receiving services paid through the Medicaid fee-for-service program. Additional information about the Medicaid MCO program can be found at http://www.dmas.virginia.gov/Content_pgs/mc-home.aspx.

Effective December 1, 2013, DMAS awarded a contract for a Behavioral Health Services Administrator (BHSA) to Magellan Health Services. Magellan administers a coordinated care model for behavioral health services for Medicaid and FAMIS members with fee-for-service (FFS) coverage, including members who participate in Medicaid home and community based waiver programs. Magellan also administers a subset of community behavioral health and rehabilitation services that are excluded (“carved-out”) from DMAS MCO contracts. Magellan performs administrative functions such as provider enrollment, service authorization and claims payment, as well as supporting a call center for members and providers. Telemedicine for both behavioral health services for individuals in the FFS program and for behavioral health services that are carved out of the MCO program is administered by Magellan. For further information on the BHSA and Magellan, DMAS issued “Medicaid Memo” documents on July 2, 2013, August 28, 2013 and October 31, 2013. These are available from DMAS at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders


TELEMEDICINE DELIVERED SERVICES BY OUT-OF-STATE PHYSICIANS:


DMAS is expanding access, through the use of telemedicine, to out-of-state physicians for the Medicaid and FAMIS populations. Physicians may be physically located outside of Virginia but must be located within the continental United States. DMAS telemedicine coverage for out-of-state physicians does not include other out- of-state providers such as nurse practitioners.

Attachment A and Attachment B list the procedure codes for which telemedicine may be utilized. Physicians who are out-of-state may utilize telemedicine for the delivery of services as noted under the column heading “Out-of-State DMAS Enrolled Physicians” on Attachment A. Out-of-state physicians considered by DMAS as in-state, (located within 50 miles from the Virginia border as described below), may utilize telemedicine for the delivery of services, as noted under the column heading “In-State DMAS Enrolled Providers” on Attachment A. The Behavioral Health Services with an asterisk on Attachment A are coordinated by Magellan.

Equipment utilized for telemedicine must be of sufficient audio quality and visual clarity as to be functionally equivalent to a face-to-face encounter for professional medical services. Staff must be proficient in the operation and use of the telemedicine equipment. Telemedicine encounters must be conducted in a confidential manner, and any information sharing must be consistent with applicable federal and state laws and regulations and DMAS policy. Health Information Portability and Accountability Act of 1996 (HIPAA) confidentiality requirements are applicable to telemedicine encounters.

Provider Enrollment:

Newly enrolling out-of-state physicians who enter on their enrollment application a service address that is within 50 miles of the Virginia border may be enrolled as in-state providers. These physicians may request an effective date for DMAS reimbursement of claims up to one year prior to enrollment to capture past claims. The effective date for physicians with a service address beyond 50 miles of the Virginia border will be the first date of service on a submitted claim (or supporting documentation).

The services a physician anticipates billing to DMAS will determine whether the physician should enroll using the DMAS subcontractor Xerox, or the DMAS subcontractor Magellan, as indicated below. Out-of-state physicians interested in providing services other than behavioral health services via telemedicine, must enroll with Xerox. Physicians wishing to provide behavioral health services must enroll with Magellan. Physicians wishing to provide both behavioral and non-behavioral health services must enroll with both Xerox and Magellan. Billing DMAS for the evaluation and management and hospital care procedure codes on Attachment A may require that the provider enroll with Xerox or Magellan or both entities, depending on whether the member’s diagnosis involves behavioral health care and/or non-behavioral health care.

Xerox Provider Enrollment- Out-of-State Physicians:

Application for enrollment may be made online or through a completed paper application sent to the Xerox Provider Enrollment Services unit. Instructions on how to access the online and paper applications are on the Virginia Medicaid web portal https://www.virginiamedicaid.dmas.virginia.gov/wps/portal. The following information must be provided when applying for enrollment:

  • Virginia Department of Health Professions medical licensure information for the physician,
  • Non-Virginia state medical licensure information for the physician, and
  • Physician attests on the enrollment form to question 11, by marking “Yes” in response to “Are you currently enrolled as a provider in the Medicaid program in the state in which you are residing?”

Physicians must select the “telemedicine” specialty and other specialties as appropriate. Magellan Provider Enrollment- Out-of-State Physicians: Out-of-state physicians interested in providing behavioral health services utilizing telemedicine must enroll with Magellan. Provider enrollment information is available at the Magellan website. http://www.magellanofvirginia.com. The website includes the provider handbook and information on training sessions and the enrollment process. The following information must be provided when applying for enrollment:

  • Virginia Department of Health Professions medical licensure information for the physician,
  • Non-Virginia state medical licensure information for the physician, and
  • Physician attests on the enrollment form to question 11, by marking “Yes” in response to “Are you currently enrolled as a provider in the Medicaid program in the state in which you are residing?”

BILLING FOR COVERED TELEMEDICINE SERVICES:


All providers utilizing telemedicine and billing for services must be enrolled with DMAS. All coverage requirements described in the DMAS provider manuals apply when the service is delivered via telemedicine. The use of telemedicine must be noted in the service documentation of the patient record.

Telephone calls, e-mail, facsimile transmissions and similar electronic measures are not considered part of the telemedicine coverage and are not to be billed to DMAS, including its subcontractors.
A description of services that may be delivered via telemedicine is included at Attachment A and Attachment B. The services include: evaluation and management, psychiatric care, specialty medical procedures such as echocardiography and obstetric ultrasound, speech therapy, and radiology procedures. Attachment A also includes the remote provider groups recognized by DMAS for reimbursement of services. These provider groups include out-of-state and in-state physicians and in-state nurse practitioners, clinical nurse specialists, nurse midwives, psychiatrists, clinical psychologists, clinical social workers, professional counselors, psychiatric clinical nurse specialists, psychiatric nurse practitioners, marriage and family therapists/counselors licensed by the Virginia Board of Counseling, school psychologists licensed by the Virginia Department of Health Profession’s Board of Psychology, substance abuse treatment practitioners and Local Education Agencies.

When billing for services delivered via telemedicine, either the “GT” (via interactive audio and video telecommunications system) or the “GQ” (via asynchronous telecommunications system) procedure modifier must be entered on the claim, as noted on Attachment A. Services billed where telemedicine is the mode of service delivery but the claim form and/or service documentation do not indicate telemedicine (using the procedure modifiers or appropriate revenue codes) are subject to disallowances in the course of an audit.

The provider groups recognized by DMAS whose offices or other locations may serve as the originating site for telemedicine encounters are found at footnote g. in Attachment A. The originating site provider, who is enrolled with DMAS and affiliated with the office or other location where the Medicaid member is located for the telemedicine encounter, is to bill the procedure code Q3014 (telemedicine facility fee) with the GT or GQ modifier entered on the claim. The only procedure code originating sites may bill is Q3014. The originating site provider or designee must attend the encounter with the member, unless the encounter documentation in the patient record notes the reason staff was not present. Reasons may include instances where the member is reporting injuries due to physical abuse or psychiatric care where the member may feel uncomfortable with an additional person involved in the telemedicine encounter.

Originating site providers, such as hospitals and nursing homes submitting UB-04/CMS-1450 claim forms, must include the appropriate telemedicine revenue code of 0780 (“Telemedicine-General”) or 0789 (“Telemedicine-Other”). The use of these codes is currently not applicable for services administered by Magellan.

The services and provider types that are eligible for reimbursement when using telemedicine may be changed, as determined necessary by DMAS. Questions about DMAS telemedicine coverage may be directed to vatelemedicine@dmas.virginia.gov.


VIRGINIA MEDICAID WEB PORTAL

DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: www.virginiamedicaid.dmas.virginia.gov. If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free, at 1-866-352-0496 from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. The MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1-800-772- 9996. Both options are available at no cost to the provider. Providers may also access service authorization information including status via KEPRO’s Provider Portal at http://dmas.kepro.com.

“HELPLINE” The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays. The “HELPLINE” numbers are: 1-804-786-6273 Richmond area and out-of-state long distance 1-800-552-8627 All other areas (in-state, toll-free long distance)

Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Identification Number available when you call.


Attachment A
Services Under DMAS Telemedicine Coverage

CPT, HCPCS Billing Codes; Modifiers: Brief Service Description: In-State DMAS
Enrolled Providers:
Out-of-State DMAS
Enrolled Physicians:
57452, 57454, 57455, 57456, 57460, 57461 Colposcopy a. a.
59025 Fetal non-stress test a. a.
70010-79999 and radiology related procedures as covered by DMAS, GQ modifier if store and forward

Radiology and radiology related procedures

a. a.
76801, 76802, 76805, 76810, 76811-76817 Obstetric ultrasound a. a.
76825, 76826 Echocardiography, fetal a. a.
90791, 90792 Psychiatric diagnostic interview examination* d. a.
90832, 90833, 90834, 90836, 90837, 90838 Individual psychotherapy* d. a.
90846 Family psychotherapy (without the patient present)* d. a.
90847 Family psychotherapy (conjoint psychotherapy) (with patient present)* d. a.
90853 Group psychotherapy (other than of a multiple-family group)* d. a.
92227, 92228 modifiers 26 if applicable, GQ if store-and-forward Remote imaging for detection of diabetic retinopathy; remote imaging for monitoring and management of diabetic retinopathy with physician review, interpretation and report d. a.
92250, modifiers TC if applicable, GQ if store-and-forward Remote imaging using fundus photography for monitoring and management of diabetic retinopathy, with interpretation and report a. a.
92506-92508 Speech therapy e.  
92601-92604, 95974 Diagnosis, analysis cochlear implant function a. a.
93010 Cardiography interpretation and report a. a.
93307, 93308, 93320, 93321, 93325 Echocardiography a. a.
99201-99215 Evaluation and management-office visits or other outpatient visits * (can be a BHSA service) a., b., c. a.
99201-99215, GQ store and forward Evaluation and management-office visits or other outpatient visits- teledermatology services a. a.
99221-99223, 99231-99233 Initial and subsequent hospital care * (can be a BHSA service) a. a.
99304-99306, 99307-99310 Initial and subsequent physician nursing home care a. a.
H0036 Crisis intervention* f.  
H0050 with HM, HN, HO or HQ modifier Substance abuse crisis intervention* f.  
Q3014 Telemedicine Facility Fee g.  



*Magellan Health Services is the DMAS Behavioral Health Services Administrator, which includes service authorization.

Key to above tables:
a.
Physician, considered a remote provider
b.
Nurse practitioner and clinical nurse specialist, considered remote providers
c.
Nurse midwife, considered a remote provider
d.
Psychiatrist, clinical psychologist, clinical social worker; professional counselor; a psychiatric clinical nurse specialist; a psychiatric nurse practitioner; marriage and family therapist/counselor licensed by the Virginia Board of Counseling; a school psychologist licensed by the Virginia Department of Health Profession’s Board of Psychology; and substance abuse treatment practitioner. All these providers are considered as remote providers.
e.
Local Education Agency (billing speech therapy), considered a remote provider
f.
Providers must have the appropriate required license from the Department of Behavioral Health and Developmental Services (http://www.dbhds.virginia.gov/) and enrolled with Magellan. These providers are considered as remote providers.
g.
Provider locations a.-f. above plus Rural Health Clinics; Federally Qualified Health Centers; Hospitals (includes general, state mental, private mental, long stay, rehabilitation); Nursing Facilities (includes skilled nursing, medical /intellectual disability, intermediate care); Health Department Clinics; Renal Units (dialysis centers); Community Services Boards (mental health-intellectual disability provider); and Residential Treatment Centers-C. All providers in this paragraph are considered as originating site providers.


Notes:

Physicians determined by DMAS to be out-of-state will be reimbursed for the professional component amount for the billed service or procedure if the amount is specified on the DMAS reimbursement file.

All procedures are to be billed with the GT modifier unless the GQ modifier is noted.

The effective date for radiology and radiology-related procedures is April 1, 2014 for both in-state and out-of-state physicians.

The effective date for behavioral health services provided by out-of-state physicians is April 1, 2014.



Attachment B
Radiology Related Procedures for Physician Billing Included under Telemedicine Coverage

Procedure Title (Reduced Length):

Fine needle aspiration; with imaging guidance

Biopsy of breast; percutaneous, needle core, using image guidance

Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device

Preoperative placement of needle localization wire, breast;

Image guided placement, metallic localization clip, percutaneous, breast biopsy/aspiration

Arthrocentesis, aspiration, and/or injection; major joint or bursa

Transcatheter occlusion or embolization (eg, for tumor destruction, other)

Hepatotomy; for percutaneous drainage of abscess or cyst, one or two stage

Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance

Electrocardiogram, routine ecg with at least 12 leads; with interpretation

Electrocardiogram, routine ecg with at least 12 leads; interpretation and report only

Echocardiography, transthoracic, real-time with image documentation (2d)

Duplex scan of extremity veins including responses to compression and other

Duplex scan of extremity veins including responses to compression and other

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, other organs

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, other organs

CPT Code:

10022

19102

19103

19290

19295

20610

37204

47011

49083

93000

93010

93306

93970

93971

93975

93976