Covered and Noncovered Services : Covered Services and Requirements

Telehealth

Information is available for DOS before January 1, 2020.

Information is available for DOS between January 1, 2020 and March 1, 2020.

ForwardHealth allows certain covered services to be provided via telehealth (also known as "telemedicine"). Telehealth enables a provider who is located at a distant site to render the service remotely to a member located at an originating site using a combination of interactive video, audio, and externally acquired images through a networking environment.

Allowable Providers

There is no restriction on the location of a distant site provider. The following types of providers may be reimbursed for providing telehealth services at a distant site:

• Audiologists
• Individual mental health and substance abuse practitioners not in a facility certified by the DQA
• Nurse midwives
• Nurse practitioners
• Ph.D. psychologists
• Physician assistants
• Physicians
• Psychiatrists
• Professionals providing services in mental health or substance abuse programs certified by the DQA

Allowable Originating Sites

For DOS on or after March 1, 2020, ForwardHealth will allow coverage of telehealth for any originating site. However, only the following originating sites will be eligible for a facility fee reimbursement:

• Hospitals, including emergency departments
• Office/clinic
• Skilled nursing facility

Requirements and Restrictions

Services provided via telehealth must be of sufficient audio and visual fidelity and clarity as to be functionally equivalent to a face-to-face visit where both the rendering provider and member are in the same physical location. Both the distant and originating sites must have the requisite equipment and staffing necessary to provide the telehealth service.

Coverage of a service provided via telehealth is subject to the same restrictions as when the service is provided face-to-face (e.g., allowable providers, multiple service limitations, PA).

Providers are reminded that HIPAA confidentiality requirements apply to telehealth services. When a covered entity or provider utilizes a telehealth service that involves PHI, the entity or provider will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity, and availability. Each entity or provider must assess what are reasonable and appropriate security measures for their situation.

Note: Providers may not require the use of telehealth as a condition of treating a member. Providers must develop and implement their own methods of informed consent to verify that a member agrees to receive services via telehealth. These methods must comply with all federal and state regulations and guidelines.

Noncovered Services

The following are not covered as telehealth services:

• Store and forward services (defined as the asynchronous transmission of medical information to be reviewed at a later time by a provider at a distant site)
• Services that are not covered when delivered face-to-face

Claims Submission and Reimbursement for Distant Site Providers

Claims for services provided via telehealth by distant site providers must be billed with the same procedure code as would be used for a face-to-face encounter along with HCPCS modifier GT (via interactive audio and video telecommunication systems).

Claims must also include POS code 02 (Telehealth: the location where health services and health-related services are provided or received through telehealth telecommunication technology). ForwardHealth reimburses the service rendered by distant site providers at the same rate as when the service is provided face-to-face.

Ancillary Providers

Claims for services provided via telehealth by distant site ancillary providers should continue to be submitted under the supervising physician's NPI using the lowest appropriate level office or outpatient visit procedure code or other appropriate CPT code for the service performed. These services must be provided under the direct on-site supervision of a physician who is located at the same physical site as the ancillary provider and must be documented in the same manner as services that are provided face to face.

Pediatric and Health Professional Shortage Area-Eligible Services

Claims for services provided via telehealth by distant site providers may additionally qualify for pediatric (services for members 18 years of age and under) or HPSA-enhanced reimbursement. Pediatric and HPSA-eligible providers are required to indicate POS code 02, along with modifier GT and the applicable pediatric or HPSA modifier, when submitting claims that qualify for enhanced reimbursement.

Claims Submission and Reimbursement for Originating Site Facility Fee

In addition to reimbursement to the distant site provider, ForwardHealth reimburses an originating site facility fee for the staff and equipment at the originating site requisite to provide a service via telehealth. Eligible providers who serve as the originating site should bill the facility fee with HCPCS procedure code Q3014 (Telehealth originating site facility fee). HCPCS modifier GT should not be included with procedure code Q3014.

Eligible providers who bill on a professional claim form should bill Q3014 with a POS code that represents where the member is located during the service. The POS must be a ForwardHealth-allowable originating site for procedure code Q3014 in order to be reimbursed for the originating site fee. The originating site fee is reimbursed based on a maximum allowable fee.

Eligible providers who bill on an institutional claim form should bill Q3014 as a separate line item with the appropriate revenue code. ForwardHealth will reimburse these providers for the facility fee based on the provider's standard reimbursement methodology.

Documentation Requirements

All services provided via telehealth must be thoroughly documented in the member's medical record in the same manner as services provided face-to-face. As a reminder, documentation for originating sites must support the member's presence in order to submit a claim for the originating site facility fee. In addition, if the originating site provides and bills for services in addition to the originating site facility fee, documentation in the member's medical record should distinguish between the unique services provided.

Telestroke Services

Telestroke, also known as stroke telemedicine, is a delivery mechanism of telehealth services that aims to improve access to recommended stroke treatment.

ForwardHealth allows providers to be reimbursed for telestroke services. Telestroke services typically consist of the member and emergency providers at an originating site consulting with a specialist located at a distant site.

Claims Submission for Telestroke Services

Providers are required to use CPT consultation and E&M procedure codes when billing telestroke services. Telestroke services are subject to the same enrollment policy, coverage policy, and billing policy as telehealth services. All other services rendered by the provider at the originating site, and by any providers to which the member is transferred, should be billed in the same manner as visits or admissions that do not involve telehealth services.

Originating sites that have established contractual relationships for telestroke services may bill as they would for any other contracted professional services for both the professional service claim on behalf of the distant site provider and the originating site fee.

Additional Policy for Certain Types of Providers

Out-of-State Providers

ForwardHealth policy for services provided via telehealth by out-of-state providers is the same as ForwardHealth policy for services provided face-to-face by out-of-state providers. Out-of-state providers who do not have border status enrollment with Wisconsin Medicaid are required to obtain PA before providing services via telehealth to BadgerCare Plus or Medicaid members.

Note: Wisconsin Medicaid is prohibited from paying providers located outside of the United States and its territories, including the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Community Health Centers, Tribal Federally Qualified Health Centers, and Rural Health Clinics

CHCs, tribal FQHCs, and RHCs may serve as originating site and distant site providers for telehealth services.

Distant Site

Tribal FQHCs and RHCs may report services provided via telehealth on the cost settlement report when the FQHC or RHC served as the distant site and the member is an established patient of the tribal FQHC or RHC at the time of the telehealth service.

Services billed with modifier GT (modifier indicating telehealth) will be considered under the PPS reimbursement method for non-tribal FQHCs. Billing HCPCS procedure code T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS rate for fee-for-service encounters.

Originating Site

The originating site facility fee is not a tribal FQHC or RHC reportable encounter on the cost report. Any reimbursement for the originating site facility fee must be reported as a deductive value on the cost report.

For CHCs, originating site services should be billed, but no reimbursement will be issued as all costs for providing originating site services have already been incorporated into the PPS rates for CHCs. Claims billed by CHCs for originating site services may be used for future rate setting purposes.

Allowable Services

ForwardHealth only covers telehealth delivery of individual services. For those procedure codes that can be used for either individual or group services, providers may not submit claims for telehealth delivery of group services. Allowable providers may be reimbursed, as appropriate, for the following services (and applicable procedure codes) provided through telehealth.

Note: The use of E&M codes is subject to E&M documentation guidelines.

^* Telehealth services that are medical in nature and would otherwise be coded as an office visit or consultation evaluation and management visit are covered for members residing in a skilled nursing facility. Some Nursing Facility Service Assessments are not covered as telehealth services (e.g. 99304–99318). Domiciliary, Rest Home, or Custodial Care Services and Oversight Services (codes 99324–99340) are not allowable as telehealth services.