Provider Alert! Telemedicine/Telehealth claims guidanceTexas Children's Health Plan
Date: November 21, 2022
Attention: All Providers
Effective Date: October 25, 2022
Federally Qualified Health Centers (FQHC) reimbursement for Telemedicine (Physician Delivered) and Telehealth (Non-Physician Delivered) Services as a distant site provider as permanent policy change (per S.B. 670, Texas Legislature, Regular session 2019) ended November 30, 2020 as announced by the Health and Human Services Commission.
The content in this message on Rural Health Clinics as telehealth and telemedicine sites will remain in effect through March 31, 2022 as announced by the Health and Human Services Commission.
TCHP COVID-19 Utilization Management Procedure and TCHP 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(non-physician-delivered) and telemedicine distant site services to its members. The purpose of this alert is to provide guidance on billing practices for these services.
Texas Health Steps Telemedicine Guidance for Providers
Visit the Health and Human Services website for updates regarding the guidance permitting remote delivery of certain components of Texas Health Steps medical checkups.
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.
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.
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.
- 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
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.
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 end of the disaster declaration period:
Medical Services: 99201-99205 and 99211-99215
Behavioral Health Services:
- Screening, Brief Intervention, and Referral to Treatment (SBIRT): H0049, G2011, 99408
- Health and Behavior Assessment and Intervention (HBAI) Services: 96156, 96158, 96159, 96164, 96165, 96167, 96168
Mental Health Rehabilitation: H0034, H2011, H2012, H2014, H2017
Effective May 1, 2022, through October 31, 2022, HHSC authorizes Medicaid FFS providers to submit claims for reimbursement of the following services delivered by synchronous audio-visual and telephone (audio-only) technology:
|Description of Service||Procedure Codes|
|Psychiatric Diagnostic Evaluation||90791, 90792|
|Psychotherapy||90832, 90834, 90837, 90846, 90847, 90853|
|Peer Specialist Services||H0038|
|Mental Health Rehabilitation||H0034, H2011, H2014, H2017|
|Mental Health Targeted Case Management (MHTCM) Services||T1017|
|Psychiatric Evaluation & Management (E/M) Services and Pharmacological Management||99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215|
The COVID-19 flexibility to allow audio-only delivery of Substance Use Disorder – Assessment and Counseling Services: H0001, H0004, H0005 will end effective May 31, 2022.
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 Rural Health Care Centers (RHC)
Ended March 31, 2022:
RHC providers performing patient-site telemedicine services may be reimbursed for the facility fee (procedure code Q3014) as an add-on procedure code.
Procedure code Q3014 will be a benefit for RHC providers when telemedicine services are rendered in the office or outpatient hospital setting.
More than one facility fee for the same client on the same date of service may be reimbursed for multiple distant-site provider consultations, when medically necessary.
If an RHC is eligible for payment of both an encounter fee and a telemedicine facility fee for the same client on the same date of service, the RHC must submit a claim for the facility fee separate from the claim submitted for the encounter. The facility fee should not be included in any cost reporting that is used to calculate the RHC All Inclusive Rate (AIR) prospective payment system (PPS) per visit encounter rate.
TCHP will reimburse RHCs as telemedicine (physician-delivered) service distant site providers effective immediately in an “Audio-visual” or “Audio Only” format. 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 RHC encounter billing. These codes may be used for Audio-visual or Audio only formats with appropriate documentation:
RHC Encounters: Procedure Codes 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) to indicate use of the telehealth or telemedicine modality. 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 March 31, 2022.
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) 10- Patient’s home
Effective January 1, 2022, POS Code 10 is available for providers who provide telehealth services to patients who attend the telehealth appointments in their own homes. Providers should continue to use POS code 02 when telehealth is provided and the patients attend the telehealth appointments anywhere other than their own homes (e.g., a hospital or skilled nursing facility).
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 designated specialties, limited to FP, IM, Pedi, OB/GYN, 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.