TELEMEDICINE POLICY Form

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ALABAMA MEDICAID AGENCY

TELEMEDICINE POLICY Effective: June 1, 2023 Revised: May 26, 2023 For all updates related to this policy beginning July 1, 2023, please refer to Chapter 112 – Telemedicine Services in the Provider Billing Manual located on the Medicaid website: Alabama Medicaid.

Overview

This general information is related to the telehealth medical services rendered by Alabama Medicaid (Medicaid) providers. Providers are expected to comply with Alabama’s Telehealth Medical Services law (Code of Alabama, Sections 34-24-701 through 34-24-707) at all times.

Definitions

As found in Alabama law the following definitions apply to Medicaid’s telemedicine policy: • Telehealth medical services means “digital health, telehealth, telemedicine, and the applicable technologies and devices used in the delivery of telehealth. The term does not include incidental communications between a patient and a physician. o Digital Health is defined as “the delivery of health care services, patient education communications, or public health information via software applications, consumer devices, or other digital media.” o Telehealth is defined as “the use of electronic and telecommunications technologies, including devices used for digital health, asynchronous and synchronous communications, or other methods, to support a range of medical care and public health services.” o Telemedicine is defined as “a form of telehealth referring to the provision of medical services by a physician at a distant site to a patient at an originating site via asynchronous or synchronous communications, or other devices that may adequately facilitate and support the appropriate delivery of care. The term includes digital health but does not include incidental communications between a patient and a physician.” • The term irregular or infrequent services refers to “telehealth medical services” occurring less than 10 days in a calendar year or involving fewer than 10 patients in a calendar year. • Synchronous is defined as “the real-time exchange of medical information or provision of care between a patient and a physician via audio/visual technologies, audio-only technologies, or other means.”

Telemedicine Provider Requirements

• Providers must submit the Telemedicine Service Agreement/Certification to Medicaid’s fiscal agent. The form is located on the Medicaid website at: www.medicaid.alabama.gov. • Providers must be enrolled with Medicaid with a specialty type of 931 (Telemedicine Service).
• Providers must identify themselves to the recipient with their credentials and name at the time of service.

2 THE CURRENT PROCEDURAL TERMINOLOGY (CPT) AND CURRENT DENTAL TERMINOLOGY (CDT) CODES DESCRIPTORS, AND OTHER DATA ARE COPYRIGHT © 2023 AMERICAN MEDICAL ASSOCIATION AND © 2023 AMERICAN DENTAL ASSOCIATION (OR SUCH OTHER DATE PUBLICATION OF CPT AND CDT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS APPLY • Providers must obtain prior written or verbal consent from the recipient before services are rendered. • Telemedicine services may only be provided as a result of a patient’s request, part of an expected follow up, or a referral from the patient’s licensed physician with whom the patient has an established patient-physician relationship.
• Services rendered via telecommunication system must be provided by a provider who is licensed, registered, or otherwise authorized to engage in his or her healthcare profession in the state where the patient is located. Per Alabama law, the provision of telemedicine medical services is deemed to occur at the patient's originating site within this state.
• Services must be within the provider’s scope of license. • Services must be provided to a recipient that is an established patient of the provider or practice or due to a referral made by a patient's licensed physician with whom the patient has an established physician-patient relationship, in the usual course of treatment of the patient's existing health condition. • Telemedicine services provided to minors under the age of medical consent must have a parent or legal guardian attend the telemedicine visit.
• Only the provider rendering the services via telemedicine may submit for reimbursement for services. • Providers must indicate an in-state or qualifying bordering state site of practice address from which telemedicine services will be provided. Note: A covered telemedicine service will count as part of each recipient’s benefit limit of 14 annual physician office visits currently allowed, if applicable. Further, nothing in this policy expands or grants any authority outside that authority granted to the provider by their respective licensure board or by federal or state law.
Delivery Requirements of Telemedicine Services

• Services must be administered via an interactive audio or audio and video telecommunications system which permits two-way communication between the distant site provider and the site where the recipient is located (this does not include electronic mail message or facsimile transmission between the provider and recipient).
• Telemedicine health care providers shall ensure that the telecommunication technology and equipment used is sufficient to allow the health care provider to appropriately evaluate, diagnose, and/or treat the recipient for services billed to Medicaid and is HIPAA compliant.
• Transmissions must utilize an acceptable method of encryption adequate to protect the confidentiality and integrity of the transmission information. Transmissions must employ acceptable authentication and identification procedures by both the sender and the receiver. • The provider shall implement confidentiality protocols that include, but are not limited to:
a. specifying the individuals who have access to electronic records;
b. usage of unique passwords or identifiers for each employee or other person with access to the client records;
c. ensuring a system to prevent unauthorized access, particularly via the internet; and
d. ensuring a system to routinely track and permanently record access to such electronic medical information. • These protocols and guidelines must be available for inspection at the telemedicine site and to Medicaid upon request.

3 THE CURRENT PROCEDURAL TERMINOLOGY (CPT) AND CURRENT DENTAL TERMINOLOGY (CDT) CODES DESCRIPTORS, AND OTHER DATA ARE COPYRIGHT © 2023 AMERICAN MEDICAL ASSOCIATION AND © 2023 AMERICAN DENTAL ASSOCIATION (OR SUCH OTHER DATE PUBLICATION OF CPT AND CDT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS APPLY Provider Types Eligible for Reimbursement for Telemedicine Services

Physicians Certified Registered Nurse Practitioners (CRNPs) Physician Assistants Rehabilitative Option Providers Psychologists Licensed Professional Counselors Associate Licensed Counselors Licensed Marriage and Family Therapist and Associates Licensed Master Social Workers Licensed Independent Clinical Social Workers Licensed Psychological Technicians Speech Therapists
Optometrists Applied Behavior Analysts Early Intervention Children’s Rehabilitation Service Pharmacists/Pharmacies Targeted Case Management

Refer to the respective Alabama Medicaid Provider Billing Manual chapter that describes the service provided by providers listed above for further information.

Covered Services Eligible for Reimbursement for Telemedicine Services

Procedure codes listed below are reimbursable services when delivered via telemedicine by a provider type listed above. The procedure codes are listed below by provider type or services. For further detailed information, refer to the below chapters of the Provider Billing Manual (updated January, April, July, and October). The Provider Billing Manual is located on Medicaid’s website, www.medicaid.alabama.gov, under the Providers tab.

Eye Care – Chapter 15 • Office visit codes for established patients: CPT 99211-99215

CRNPs/PAs Services– Chapter 21
• Office or other outpatient visits for recipients ages 21 and older: CPT 99202-99205, 99211- 99215 • EPSDT interperiodic screenings: CPT 99211 EP-99215 EP • Initial hospital inpatient or observation care: CPT 99221-99223 • Subsequent hospital inpatient or observation care: CPT 99231-99233 • Hospital inpatient or observation care: CPT 99234-99236 • Hospital inpatient or observation discharge day management: CPT 99238-99239 • Office or other outpatient consultation: CPT 99242-99245 • Inpatient or observation consultation: CPT 99252-99255

Physician services – Chapter 28 • Office or other outpatient visits for recipients ages 21 and older: CPT 99202-99205, 99211- 99215
• EPSDT interperiodic screenings: CPT 99211 EP - 99215 EP • Initial hospital inpatient or observation care: CPT 99221-99223 • Subsequent hospital inpatient or observation care: CPT 99231-99233 • Hospital inpatient or observation care: CPT 99234-99236 • Hospital inpatient or observation discharge day management: CPT 99238-99239 • Office or other outpatient consultation: CPT 99242-99245 • Inpatient or observation consultation: CPT 99252-99255

Behavioral Health – Chapter 34 • Psychotherapy: CPT 90832, 90834, 90837, 90846, 90847 and HCPCS H2011 [psychologist only]

4 THE CURRENT PROCEDURAL TERMINOLOGY (CPT) AND CURRENT DENTAL TERMINOLOGY (CDT) CODES DESCRIPTORS, AND OTHER DATA ARE COPYRIGHT © 2023 AMERICAN MEDICAL ASSOCIATION AND © 2023 AMERICAN DENTAL ASSOCIATION (OR SUCH OTHER DATE PUBLICATION OF CPT AND CDT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS APPLY Applied Behavioral Analysis Therapy – Chapter 37 • Behavior Identification Assessment: CPT 97151 • Observational F/U assessment: CPT 97152 • Exposure Behavioral F/U Assessment: HCPCS 0362T • Adaptive Behavior Treatment: CPT 97153 • Group Adaptive Behavior Treatment: CPT 97153 • Social Skills Group: CPT 97154 • Exposure Adaptive Behavior Treatment: HCPCS 0373T • Adaptive Behavior Modification: CPT 97155 • Family Adaptive Behavior Treatment Guidance: CPT 97156 • Multiple Family, Group Treatment Guidance: CPT 97157

Speech Therapy – Chapter 37 • Treatment of speech: CPT 92507, 92508 • Evaluation of speech sound production: CPT 92523

Children’s Rehabilitation Service – Chapter 100 • Office visits: CPT 99202 HT, 99203 HT, 99204 HT, 99205 HT, 99212 HT, 99213 HT, 99214 HT, 99215 HT Rehabilitative Option Services– Chapter 105 • Psychiatric evaluation: CPT 90791, 96130, 96131 • Psychotherapy: CPT 90832, 90834, 90837, 90846, 90847, 90853, 90849 • Psychological testing: CPT 96136, 96137, 96138, 96139, 96146 • Assessments: HCPCS H0002, H0004, H0031-HR • Medication Monitoring: HCPCS H0034 • Peer support services: HCPCS H0038 (with appropriate modifiers)
• Program for Assertive Community Treatment: HCPCS H0040-HQ

• Crisis intervention: CPT H2011 • Treatment plan review: HCPCS H0032 • Mental health care coordination: HCPCS H0046

Targeted Case Management – Chapter 106 • Group 1: HCPCS G9008-U1 • Group 3: HCPCS G9002-U3 • Group 9: HCPCS G9008-U9 • Group 10: HCPCS G9003-UA TG and G9008-U1 TG

Early Intervention – Chapter 108 • Intake Evaluation: HCPCS T1023 • Audiology: CPT 92550 TL, 92552 TL, 92553 TL, 92555 TL, 92556 TL, 92557 TL, 92567 TL, 92568 TL, 92579 TL, 92582 TL, 92583 TL, 92587 TL • Family Support: HCPCS H2027 TL • Psychological Testing: CPT 96111 TL • Speech-Language Pathology: CPT 92507 TL, 92508 TL, 92526 TL, 97532 TL • Vision Services: CPT 99173 TL • Treatment Plan Review: HCPCS H0032 TL

5 THE CURRENT PROCEDURAL TERMINOLOGY (CPT) AND CURRENT DENTAL TERMINOLOGY (CDT) CODES DESCRIPTORS, AND OTHER DATA ARE COPYRIGHT © 2023 AMERICAN MEDICAL ASSOCIATION AND © 2023 AMERICAN DENTAL ASSOCIATION (OR SUCH OTHER DATE PUBLICATION OF CPT AND CDT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS APPLY Provider Types Not Eligible for Reimbursement for Telemedicine Services

Physical Therapists Occupational Therapists DME suppliers Ambulance providers Chiropractors Home Infusion Laboratory

Services not Eligible for Reimbursement for Telemedicine Services

Common examples of services via telemedicine not considered for reimbursement (not exhaustive): • Chart reviews • Electronic mail messages (between providers and recipients) • Facsimile transmissions (between providers and recipients) • Consultation between two providers
• Internet based communications that are not HIPAA-compliant or secure • Services not directly provided by an enrolled provider or by office staff • Services not normally charged for during an office visit • Services not specifically listed in Provider Billing Manual chapters
• Communication that is not secure or HIPAA-compliant (e.g., Skype, FaceTime)

Exceptions may be made to the lists for providers and services not reimbursable under this policy in the event of a public health emergency, however, separate guidance would be issued in those instances.

Origination Sites

The following are required for the origination site where the patient is located: • The site provider shall ensure that the telecommunication technology and equipment used at the origination site is HIPAA compliant and is sufficient to allow the appropriate evaluation, diagnosis, and/or treatment of the patient. • The site provider shall implement protocols that ensure the same confidentiality of the telemedicine visit as for in-person visits. • Regardless of the location of the recipient, it is the provider’s responsibility to ensure the telemedicine visit meets all required HIPAA rules and regulations regarding telemedicine visits.

The following sites are recognized by Medicaid as origination sites: • Physician and practitioner offices • Hospitals • Rural Health Clinics (RHCs) • Federally Qualified Health Centers (FQHCs) • Hospital-based or CAH-based Renal Dialysis Centers (including satellites) • Skilled Nursing Facilities (SNFs) • Community Mental Health Centers (CMHCs) • Renal Dialysis Facilities
• Mobile Stroke Units • Alabama Department of Public Health

Nothing in this section is meant to prohibit telemedicine services to a recipient in their home. A recipient’s home should not be considered an origination site entitled to receive an origination site fee.

6 THE CURRENT PROCEDURAL TERMINOLOGY (CPT) AND CURRENT DENTAL TERMINOLOGY (CDT) CODES DESCRIPTORS, AND OTHER DATA ARE COPYRIGHT © 2023 AMERICAN MEDICAL ASSOCIATION AND © 2023 AMERICAN DENTAL ASSOCIATION (OR SUCH OTHER DATE PUBLICATION OF CPT AND CDT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS APPLY Telemedicine Origination Site Facility Fee

Effective April 1, 2020, Medicaid pays an origination site facility fee of $20.00. The origination fee will be limited to one per date of service per recipient and may be billed by all of the providers listed above under Origination Sites.

No origination site facility fee will be paid for an origination site not listed above. Providers must bill the procedure code Q3014, telemedicine origination site facility fee, on a CMS-1500 or UB-04 claim.
Federally Qualified Health Centers and Rural Health Clinics should bill Q3014 independent of the encounter rate on a CMS-1500 claim form. Note: If a Medicaid-enrolled provider performs another medically necessary service(s), the provider may bill for the covered service(s) in addition to providing his/her facility as an origination site and be eligible for reimbursement for the origination site facility fee and the other medically necessary service(s).

Billing for Telemedicine Services

Providers meeting the telemedicine provider requirements listed above must append the modifier GT to all procedure codes billed for covered telemedicine services via audio and visual telecommunications. Additional modifiers may be required; see the chapter of the Provider Billing Manual that describes services provided for further information. At this time, reimbursement for services provided through telemedicine via audio and audio and video telecommunications will be paid at parity to those services provided face-to- face. Medicaid will continue to monitor and reevaluate, if deemed necessary. On October 1, 2023, new rates for audio-only telecommunications will be established. Providers should place a FQ modifier on an audio-only telemedicine claim to designate that the claim was delivered through audio-only telecommunications.

Note: The BMI will be required for office visits including the telemedicine visits. Providers should use subjective data to calculate the BMI which can include providers asking the recipient for his or her height and weight during the telemedicine visit. The BMI should be calculated, based on the information provided by the recipient, and appended to the claim for reimbursement. The BMI should also be documented in the recipient’s medical record.

Prior Authorization

Prior authorization is not required for services to be delivered via telemedicine, though prior authorization may be required for the individual procedure codes billed. Refer to the Provider Billing Manual chapter that describes the service provided for prior authorization requirements.

Prescribing of Medications and Controlled Substances via Telemedicine

In accordance with Alabama’s Telemedicine Law, an enrolled provider may prescribe a legend drug, medical supplies, or a controlled substance via telemedicine if the prescriber is authorized to do so under state and federal law. However, a prescription for a controlled substance may only be issued via telemedicine if: • The telemedicine visit includes synchronous audio or audio-visual communication using HIPAA compliant equipment with the prescriber; • The prescriber has had at least one in-person encounter with the patient within the preceding 12 months; and • The prescriber has established a legitimate medical purpose for issuing the prescription within the preceding 12 months.

BMI Services

The BMI will continue to be required for office visits including the telemedicine visits. The BMI is required at least once per calendar year on all claims with procedure codes 99201-99205, 99211- 99215, and 99241-99245 and EPSDT procedure codes 99382-99385 and 99392-99395. Providers should use subjective data to calculate the BMI which can include providers asking the recipient for his or her height and weight during the telemedicine visit. The BMI should be calculated, based on the information provided by the recipient, and appended to the claim for reimbursement. The BMI should also be documented in the recipient’s medical record.

Remote Patient Monitoring For information related to Remote Patient Monitoring, please refer to Chapter 111 - Remote Patient Monitoring (RPM) of the Provider Billing Manual.