Professional Documents
Culture Documents
Volume 36 | Number 5
I. General Information
Effective for dates of service on or after March 1, 2020, for the duration of the State Disaster Emergency
declared under Executive Order 202, herein referred to as the “State of Emergency”, New York State Medicaid
will reimburse telephonic assessment, monitoring, and evaluation and management services provided to
members in cases where face-to-face visits may not be recommended and it is appropriate for the member to
be evaluated and managed by telephone. This guidance is to support the policy that members should be
treated through telehealth provided by all Medicaid qualified practitioners and service providers, including
telephonically, wherever possible to avoid member congregation with potentially sick patients. Telephonic
communication will be covered when provided by any qualified practitioner or service provider. All telephonic
encounters documented as appropriate by the provider would be considered medically necessary for payment
purposes in Medicaid FFS or Medicaid Managed Care. All other requirements in delivery of these services
otherwise apply.
The following information applies to all Medicaid providers and providers contracted to serve Medicaid
members under Medicaid managed care plans. However, the Office of Mental Health (OMH), the Office for
People with Developmental Disabilities (OPWDD), and the Office of Addiction Services and Supports (OASAS)
have issued separate guidance on telehealth and regulations that will align with state law and Medicaid
payment policy for Medicaid members being served under their authority. Links are provided at the end of this
document.
Andrew M. Cuomo
Governor
State of New York
Donna Frescatore
Medicaid Director
Office of Health Insurance Programs
The Medicaid Update is a monthly publication of the New York State Department of Health.
In This Issue…
I. General Information ......................................................................................................... 1
II. Telephonic Reimbursement Overview.............................................................................. 3
Telephonic Payment Chart Explained .................................................................................................. 4
III. Telehealth ........................................................................................................................ 4
A. Definition of Telehealth ................................................................................................................. 4
B. Originating Site ............................................................................................................................. 4
C. Distant Site .................................................................................................................................... 4
D. Telehealth Applications (Telemedicine, Store-and-Forward, Remote Patient Monitoring) .......... 4
E. Telemedicine ................................................................................................................................. 5
F. Store-and-Forward Technology .................................................................................................... 5
G. Remote Patient Monitoring during the State of Emergency ......................................................... 5
IV. Telehealth Providers ........................................................................................................ 5
V. Confidentiality .................................................................................................................. 5
VI. Patient Rights and Consents ............................................................................................ 6
VII. Billing Rules for Telehealth Services ................................................................................ 6
A. Billing for Teledentistry Services ................................................................................................... 7
B. General Billing Guidelines ............................................................................................................ 7
C. Fee-for-Service Billing for Telemedicine by Site and Location (not telephonic) ........................... 7
D. Application-Specific Telehealth Billing Rules ................................................................................ 9
E. Medicaid Managed Care Considerations.................................................................................... 10
VIII. Options to Support Members with Limited or Lack of Access to Devices and Services .. 10
IX. Useful Links: .................................................................................................................. 11
X. Questions:...................................................................................................................... 12
March 2020 New York State Medicaid Update Special Edition pg. 2
II. Telephonic Reimbursement Overview
Payment for telephonic encounters for health care and health care support services will be supported in six different payment pathways utilizing
the usual provider billing structure. See the table below for the billing pathways available for telephonic encounters during the COVID-19 State of
Emergency by both FFS and Managed Care*: Chart Changes in Bold 3/23/2/20
Billing Telephonic Applicable Fee or Historical
Rate Code or Procedure Notes:
Lane Service Providers Rate Setting
Evaluation and Physicians, NPs, CPT Procedure Codes “99211”,
Fee New or established patients.
Lane 1 Management PAs, Midwives, Office “99441”, “99442”, and “99443”
Schedule Append GQ modifier for 99211only
Services Dentists, RNs “D9991” - Dentists
Any existing Procedure Codes for
Assessment and All other practitioners Billable by Medicaid enrolled
Fee services appropriate to be delivered
Lane 2 Patient billing fee schedule Office providers.
Schedule by telephone. Append modifier GQ for
Management (e.g., Psychologist) New or established patients.
tracking purposes.
Offsite Clinic or
Evaluation and Other (e.g., Rate Code “7961” for non-SBHC
Physicians, NPs,
Lane 3 Management Rate amb surg, New or established patients.
PAs, Midwives
Services (non- day Rate Code “7962” for SBHC
FQHC) program)
Offsite
Rate Code “4012” for non-SBHC
Evaluation and Physicians, NPs,
Lane 4 Rate Clinic New or established patients.
Management PAs, Midwives
Rate Code “4015” for SBHC
Services (FQHC)
Non-SBHC: Broadly billable by a wide range of
• Rate Code “7963” (for provider types including FQHCs,
telephone 5 – 10 minutes) Day Programs and Home Care
Clinic or (e.g., aide supervision, aid
other • Rate Code “7964” (for orientation, medication
Other practitioners telephonic 11 – 20 minutes)
Includes adherence, patient check-ins).
(e.g., Social Workers, • Rate Code “7965” (for
Assessment and FQHCs, However, see LHCSA/CHHA
dieticians, home telephonic 21 – 30 minutes)
Lane 5 Patient Rate Day assessments and RN visits which
care aides, RNs, SBHC:
Management Programs get billed under existing rates in
therapists and other • Rate code “7966” (for
and Home Lane 6).
home care workers) telephone 5 – 10 minutes)
Care
Providers • Rate code “7967” (for New or established patients.
telephonic 11 – 20 minutes)
• Rate code “7968” (for Report NPI of supervising physician
telephonic 21 – 30 minutes) as Attending.
All provider types
Other Services Covers all Medicaid services not
(e.g., Home Care,
(not eligible to bill All other as All appropriate rate codes as long as covered above. Includes LHCSA
Lane 6 ADHC programs, Rate
one of the above appropriate appropriate to delivery by telephone and CHHA assessments,
health home, HCBS,
categories) evaluations and RN visits.
peers)
*Managed care plans may have separate detailed billing guidance but will cover all services appropriate to deliver through telehealth/telephonic means to properly care
for the member during the State of Emergency. Further detail on FFS code coverage is provided below including links to specialized guidance for mental health,
substance abuse and OPWDD services.
March 2020 New York State Medicaid Update Special Edition pg. 3
Telephonic Payment Chart Explained
The chart has two basic sections. Lanes 1-2 are for use by fee schedule billers (primarily
practitioners in office-based settings) and lanes 3-6 are for all other billers that primarily
bill rates for clinic and other services. Practitioners that usually bill the fee schedule
directly should bill for telephonic services using lane 1 and 2 based on practitioner types
noted. Clinics should bill using lanes 3, 4 and 5 depending on FQHC status and
practitioner type. Lane 5 is for clinics and other programs to use for the noted
practitioners and should be used for any and all patient assessment and management
services that are appropriate to be billed telephonically unless otherwise noted. Lane 6
is reserved for all other services that do not fit into the first 5 lanes. More guidance will
be issued on lane 6 adding to the noted services but it is expected that over 90 percent of
all Medicaid telephonic billing should fall into lanes 1-5.
III. Telehealth
A. Definition of Telehealth
B. Originating Site
The originating site is where the member is located at the time health care services are
delivered to him/her by means of telehealth. Originating sites during the State of Emergency can
be anywhere the member is located. There are no limits on originating sites during the State of
Emergency.
C. Distant Site
The distant site is any location including the provider’s home that is within the fifty United
States or United States' territories. The distant is the site where the telehealth provider is
located while delivering health care services by means of telehealth. During the State of
Emergency all sites are eligible to be distant sites for delivery and payment purposes including
Federally Qualified Health Centers for all patients including patients dually eligible for Medicaid
and Medicare. This includes clinic providers working from their homes or any other location
during the State of Emergency.
NYS Medicaid has covered both remote patient monitoring provided by Certified Home Health
Agencies (CHHAs) for their patients and telemedicine for a number of years. NYS Medicaid has
recently expanded coverage of telehealth to include store-and-forward technology, additional
originating sites and additional practitioners. During the State of Emergency, all telehealth
March 2020 New York State Medicaid Update Special Edition pg. 4
applications will be covered at all originating and distant sites as appropriate to properly care for
the patient.
E. Telemedicine
F. Store-and-Forward Technology
Remote patient monitoring (RPM) uses digital technologies to collect medical data and other
personal health information from members in one location and electronically transmit that
information to health care providers in a different location for assessment and
recommendations. Monitoring programs can collect a wide range of health data from the point of
care, such as vital signs, blood pressure, heart rate, weight, blood sugar, blood oxygen levels
and electrocardiogram readings. RPM may include follow-up on previously transmitted data
conducted through communication technologies or by telephone.
Medical conditions that may be treated/monitored by means of RPM include, but are not limited
to, congestive heart failure, diabetes, chronic obstructive pulmonary disease, wound care,
polypharmacy, mental or behavioral problems, and technology-dependent care such as
continuous oxygen, ventilator care, total parenteral nutrition or enteral feeding.
During the State of Emergency, all Medicaid provider types are eligible to provide telehealth but
services should be appropriate for telehealth and should be within the provider’s scope of
practice.
V. Confidentiality
Services provided by means of telehealth must be in compliance with the Health Insurance
Portability and Accountability Act (HIPAA) and all other relevant laws and regulations governing
confidentiality, privacy, and consent (including, but not limited to 45 CFR Parts 160 and 164
[HIPAA Security Rules]; 42 CFR, Part 2; PHL Article 27-F; and MHL Section 33.13).
March 2020 New York State Medicaid Update Special Edition pg. 5
However, during the COVID-19 nationwide public health emergency, the Department of Health
and Human Services Office for Civil Rights (OCR) has issued a Notification of Enforcement
Discretion for telehealth remote communications. OCR will exercise its enforcement discretion
and will not impose penalties for noncompliance with the regulatory requirements under the
HIPAA Rules against covered health care providers in connection with the good faith provision
of telehealth during the emergency. https://www.hhs.gov/hipaa/for-professionals/special-
topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
All providers must take steps to reasonably ensure privacy during all patient-practitioner
interactions.
The practitioner shall confirm the member’s identity and provide the member with basic
information about the services that he/she will be receiving via telehealth/telephone. Written
consent by the member is not required. Telehealth/telephonic sessions/services shall not be
recorded without the member's consent.
March 2020 New York State Medicaid Update Special Edition pg. 6
Place of Service (POS) Code to be Used when Billing for Telehealth Services
POS Code Description
The location where health services and health-related services are provided or
received, through telehealth telecommunication technology. When billing
“02”
telehealth services, providers must bill with place of service code “02” and
continue to bill modifier “95”, “GT” or “GQ”.
When billing for teledentistry services, modifiers cannot be used by dentists. Additional
guidance was issued in the January 2020 Medicaid update (see link below) which allows for two
dental codes “D9995” and “D9996” to be used in place of modifiers. Both dental codes
“D9995” and “D9996” along with “Q3014” were added to the dental fee schedule.
https://www.health.ny.gov/health_care/medicaid/program/update/2020/2020-01.htm
For individuals with Medicare and Medicaid, if Medicare covers the telehealth encounter,
Medicaid will reimburse the Part B coinsurance and deductible to the extent permitted by state
law.
When services are provided via telemedicine to a member located at an originating site, the
servicing provider should bill for the telemedicine encounter as if the provider saw the member
face-to-face using the appropriate billing rules for services rendered. The CPT code for the
encounter must be appended with the applicable modifier (“95” or “GT”).
Article 28 Clinic Originating Sites Billing Under Ambulatory Patient Groups (APGs) for
Telemedicine (not telephonic)
March 2020 New York State Medicaid Update Special Edition pg. 7
attending to the member during a telemedicine encounter, a physician claim
cannot be billed to Medicaid.
2. When a separate and distinct medical service, unrelated to the reason for the
telemedicine encounter, is provided by a physician at the originating site
including Article 28 hospitals or D&TCs, the physician, nurse practitioner,
physician assistant, or midwife may bill for the medical service provided. The
CPT code billed for the separate and distinct service must be appended with the
“25” modifier.
Article 28 Distant Sites Billing Under APGs for Telemedicine (not telephonic)
March 2020 New York State Medicaid Update Special Edition pg. 8
Hospital Inpatient Billing for Telemedicine (not telephonic)
When the telehealth practitioner's services are included in the nursing home's rate, the
telehealth practitioner must bill the nursing home. If the telehealth practitioner's services are not
included in the nursing home's rate, the telehealth practitioner should bill Medicaid as if he/she
saw the member face-to-face. The CPT code billed should be appended with the applicable
modifier (“95” or “GT”). Practitioners providing services via telehealth should confirm with the
nursing facility whether their services are in the nursing home rate.
Federally Qualified Health Centers (FQHCs) Billing for Telemedicine (not telephonic)
1. FQHCs That Have "Opted Into" APGs: FQHCs that have "opted into" APGs should
follow the billing guidance outlined above for sites billing under APGs.
2. FQHCs That Have Not "Opted Into" APGs - FQHC Originating Sites:
4. If the FQHC is providing services as a distant-site provider, the FQHC may bill
their PPS rate.
Telephonic
See preceding guidance.
Store-and-Forward Technology
March 2020 New York State Medicaid Update Special Edition pg. 9
2. Reimbursement for consultations provided via store-and-forward technology will be paid
at 75 percent of the Medicaid fee for the service provided.
4. The consulting practitioner should bill the CPT code for the professional service
appended with the telehealth modifier "GQ."
1. Telehealth services provided by means of RPM should be billed using CPT code
"99091" (Collection and interpretation of physiologic data (e.g., Electrocardiography
(ECG), blood pressure, glucose monitoring) digitally stored and/or transmitted by the
patient and/or caregiver to the physician or other qualified health care professional,
qualified by education, training and licensure/regulation (when applicable) requiring a
minimum of 30 minutes of time).
3. Providers are not to bill "99091" more than one time per member per month.
1. Medicaid Managed Care (MMC) plans are required to cover, at a minimum, services that
are covered by Medicaid fee-for-service and also included in the MMC benefit package,
when determined medically necessary. Managed care plans should follow FFS
telehealth billing policy included in this guidance.
VIII. Options to Support Members with Limited or Lack of Access to Devices and
Services
• Free Wifi/internet
o Charter Communications (Spectrum) and Comcast are giving households with
K-12 and college students, and those who qualify as low-income complimentary
Wifi for 60 days
o Familes who do not have the service will also receive free installation of the
service
o Both companies are expanding Wifi hotspots to the public within the company’s
available regions
o Individuals must call company after 60 days, or they will be automatically billed
March 2020 New York State Medicaid Update Special Edition pg. 10
• Unlimited data
o Charter, Comcast, AT&T, and Verizon are offering unlimited data plans to
customers until May 13 for no additional charge
• Safelink Wireless
o Eligibility requirements must be met, which are set by each State where the
service is provided
o To qualify for Lifeline, subscribers must either have an income that is at or below
135% of the federal Poverty Guidelines, or participate in one of the following
assistance programs:
Medicaid
Supplemental Nutrition Assistance Program (SNAP) Food Stamps
Supplemental Security Income (SSI)
Federal Public Housing Assistance (Section 8)
Veterans and Survivors Pension Benefit
• CMS Guidance re Medicaid State Plan Fee-for-Service Payments for Services Delivered
Via Telehealth
https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-telehealth-services.pdf
March 2020 New York State Medicaid Update Special Edition pg. 11
• HHS Office for Civil Rights Guidance Regarding HIPAA and Telehealth:
https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-
preparedness/notification-enforcement-discretion-telehealth/index.html
• Medicare Guidance
Medicare Telemedicine Fact Sheet: https://www.cms.gov/newsroom/fact-
sheets/medicare-telemedicine-health-care-provider-fact-sheet
• Health Homes:
https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/policy
/docs/covid19_guidance_health_homes.pdf
• Home Care:
https://coronavirus.health.ny.gov/system/files/documents/2020/03/03-16-
20_home_care_services.pdf
X. Questions:
March 2020 New York State Medicaid Update Special Edition pg. 12
Development and Management at (518) 473–2160 or
Telehealth.Policy@health.ny.gov.
• Medicaid FFS coverage and policy questions may be directed to the Office of Health
Insurance Programs (OHIP) Division of Program Development and Management at
(518) 473–2160 or FFSMedicaidPolicy@health.ny.gov.
• Questions regarding FFS claiming should be directed to the eMedNY Call Center at
(800) 343–9000
March 2020 New York State Medicaid Update Special Edition pg. 13