Provider Alert! Updated! Telemedicine/Telehealth claims guidanceTexas Children's Health Plan
Attention: All Providers
Effective Date for new information: March 20, 2020 until the COVID disaster declaration period has expired
The content in this message will remain in effect throughout the COVID-19 Disaster Declaration period as announced by the office of the Texas Governor, Greg Abbott. COVID-19 Utilization Management Procedure and provider alerts can be found here: http://www.thecheckup.org/provider-alerts/
Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
Call to action: TCHP supports the delivery of telehealth and telemedicine (non-physician-delivered) distant site services to its members. The purpose of this alert is to provide guidance on billing practices for these services during this disaster declaration period.
Updated June 18, 2020: Texas Health Steps Telemedicine Guidance for Providers
Visit the HHSC website for updates to the FAQs regarding the guidance permitting remote delivery of certain components of Texas Health Steps medical checkups.
New information with an effective date that is retrospective to March 20, 2020:
- The following service codes are allowable via synchronous (audio/visual) telehealth interactions:
|96130, 96131,96132,96133,96136,and 96137||Psychological testing is limited to eight hours per member, per calendar year. Additional hours require prior authorization when medically necessary.|
|96116 and 96121||Neurobehavioral testing is limited to four hours per member, per day and eight hours per member, per calendar year. These codes will not be paid for the same date of service to the same provider as psychological testing codes 96130, 96131, 96136, and 96137. The same applies to neuropsychological testing codes 96132,96133,96136, and 96137. The provider must maintain all documentation in the client’s medical record.|
Be sure to bill with modifier 95 and the appropriate POS. The POS must reflect where the provider is located when delivering the service.
New information for claims received beginning June 1, 2020:
- As of June 1, 2020, TCHP will deny any claims received with POS12 when billed with a modifier 95 for telemedicine/telehealth.
- This requirement is per clarification from Texas Health and Human Services (TX HHSC) and Texas Medicaid Health Partnership (TMHP), that Place of Service (POS) 12-home will no longer be a payable POS for Telemedicine/Telehealth services.
- POS 12-home should only be used when the provider is delivering in person care in the patient’s home or private residence.
- Please note claims received prior to June 1, 2020 with POS 12, and modifier 95 will be accepted and adjudicated. While acceptance is NOT a guarantee of payment, TCHP will not deny these claims for the POS 12 Modifier 95 combination.
- Claims previously billed and adjudicated using POS 12 and Modifier 95 will NOT be retrospectively adjusted related to this specific billing combination.
- Providers DO NOT need to rebill previously adjudicated claims with this specific POS Modifier combination.
New information for dates of service beginning March 15, 2020:
Nutritional Counseling Services (audio-only)
Texas Health and Human Services is allowing providers to bill procedure code S9470 for nutritional counseling, dietitian visits for telephone (audio-only) counseling from March 15, 2020 through the end of the disaster declaration period.
Early Childhood Intervention (ECI) Specialized Skills Training (audio-only)
Texas Health and Human Services is allowing ECI Providers to bill procedure code T1027 for telephone (audio-only) Specialized Skills Training from March 15, 2020 through the end of the disaster declaration period.
Diagnosis code for reporting COVID-19
Effective April 10, 2020, for dates of service on or after April 1, 2020, diagnosis code U071 will be a benefit of Texas Medicaid and the Children with Special Health Care Needs Services Program for reporting COVID-19. In the previous alert, we stated that the dates of service began on February 20, 2020. A link to the notice can be found here: Correction to New COVID-19 Diagnosis code U071.
Telemedicine acceptable visit formats during COVID-19
As part of our COVID-19 Emergency Response, TCHP will add coverage of telemedicine services that are provided through synchronous “audio-visual” interactions and “audio-only” telephonic visits for this limited set of codes.
Procedure Codes allowable for “Audio Only” with appropriate documentation are permitted through the disaster declaration period:
Medical Services: 99201-99205 and 99211-99215
Behavioral Health Services:
- Psychiatric Diagnostic Evaluation: 90791, 90792
- Psychotherapy: 90832, 90834, 90837, 90846, 90847, 90853
- Peer Specialist Services: H0038
- Screening, Brief Intervention, and Referral to Treatment (SBIRT): H0049, G2011, 99408
- Substance Use Disorder Services: H0001, H0004, H0005
Mental Health Rehabilitation: H0034, H2011, H2012, H2014, H2017
For any of these telemedicine services billed, modifier 95 must be billed with the appropriate procedural CPT code(s) along with place of service code (POS) 02 – telemedicine services. Modifier 95 needs to appear on both the encounter and procedure lines.
Therapy Telehealth: Providers must bill a UB (licensed therapy assistant) or U5 (licensed therapist or physician) modifier on these claims.
Targeted Case management
This service may be delivered through synchronous audio-visual technologies or telephone (audio-only). Providers should bill procedure code T1017 using the 95 modifier to indicate that remote delivery occurred. This direction applies to the following services:
- Mental Health Targeted Case Management (MHTCM)
- Targeted Case Management for Early Childhood Intervention (ECI)
For case management providers in other programs, utilize existing billing codes and modifiers along with the 95 modifier to indicate that remote delivery occurred, including:
- Intellectual or developmental disability (IDD) case management
- Case Management for Blind and Visually Impaired Children (BVIC)
- Case Management for Children and Pregnant Women (CPW)
Telemedicine provided by Federally Qualified Health Centers (FQHC) & Rural Health Care Centers (RHC)
TCHP will reimburse FQHCs and RHCs as telemedicine (physician-delivered) service distant site providers effective immediately in an “Audio-visual” or “Audio Only” format. FQHCs and RHCs should bill for telemedicine services using the encounter and informational procedure codes outlined in the Texas Medicaid Provider Procedures Manual, Clinic and Other Outpatient Facility Services Handbook, (FQHC – Section 4.1.2 and RHC – Section 7.2). The telemedicine service must also meet applicable state statutory and rule scope-of-practice requirements.
Texas Health and Human Services Commission (HHSC) acceptable coding for FQHC and RHC encounter billing. These codes may be used for Audio-visual or Audio only formats with appropriate documentation:
FQHC Encounters: T1015 – POS 02 and Modifier 95 must be placed on both the encounter (T1015) service line as well as the procedure code service line(s). TCHP will accept POS 50 as well.
RHC Encounters: T1015 and 99381- POS 02 and Modifier 95 must be placed on both the encounter (T1015) service line as well as the procedure code service line(s). TCHP will accept POS72 as well. Please note that RHCs may provide telemedicine as distant site providers statewide for dates of service beginning March 4, 2020 through the disaster declaration period.
Place of Service Information for any Provider Type
For any telemedicine service billed, modifier 95 must be billed with the appropriate procedural CPT code(s) along with place of service code for dates of service beginning March 4, 2020. The POS must reflect where the provider is located when delivering the service:
- (POS) 02 – telemedicine services for all provider types
- (POS) 11 – office
- (POS) 50 – FQHC
- (POS) 72 – RHC
CPT Codes for Telehealth Claims:
At this time, TCHP does not allow for “asynchronous” telemedicine visits. Asynchronous visits are considered telemedicine visits where health information is forwarded electronically, stored, retrieved, reviewed and then responded to outside of a “real-time” interaction with the member patient.
How this impacts providers:
Provider Reimbursement for Telemedicine services
TCHP will reimburse providers for appropriately billed Telemedicine services (see the Texas Provider Procedures Manual and Handbooks (TMPPMH)) at an equivalent rate for a face-to-face visit.
Copays applicable to the CHIP program are to be waived for Telemedicine services.
Out-of-network (OON) PCP (FP, IM, Pedi, OBG) designated specialties only, may also provide Telemedicine services during the duration of this disaster declaration. All other OON providers must obtain prior authorization to provide care and services via telemedicine or telehealth.
Prior Authorizations and TMHP Guidance
Providers with existing authorizations do not need an additional authorization to provide the eligible service via telemedicine unless as stated above.
TCHP follows the Medical Policy for Telemedicine and Telehealth Services as written in the current Texas Medicaid Provider Procedures Manual – Telecommunication Services Handbook. Please reference: http://www.tmhp.com/manuals_pdf/tmppm/tmppm_living_manual_current/2_Telecommunication_Srvs.pdf
If you have any questions, please email Provider Network Management at: firstname.lastname@example.org.