19 comments
Will there be additional guidance regarding the delivery of Mental Health services via telehealth?
Will there be guidance regarding consent given by individuals served? We have a number of individuals in our Outpatient and medical services who would prefer to only be seen via telehealth. Will it be acceptable to simply mark a checkbox indicating that verbal consent has been obtained, or will it be required to attempt to obtain a "wet" signature? We frequently do not receive mailed documentation back and many of the people we serve do not have the necessary electronic devices to access emailed forms for signature.
Will their be guidance on the language that will need to be used for verbal consent moving forward after the PHE has ended?
Will there be guidance on the restrictions of the member (individual with Medicaid) temporarily being out of Virginia and still being able to receive telehealth services during their travel. This is more for the Early Intervention targeted case management piece.
Will there be guidelines on determining when 'telehealth' is appropriate or not? Early Intervention services are to occur in the home and I wanted to find out what parameters will be put in place to make sure families give fully informed consent for the services to be held via telehealth?
Fairfax- Falls Church Community Board Services agrees and supports all the comments to date below:
If a Provider, whether at the originating site or distant site, maintains a consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services including the information noted above, this shall meet DMAS’s required documentation of patient consent.
Please provide clarity and additional information around when an in-person visit is deemed clinically appropriate. Clarification regarding when telehealth is deemed not clinically appropriate in addition is needed.
Telemedicine
Distant site Providers must include the modifier GT on claims for services delivered via telemedicine. Place of Service (POS), the two-digit code placed on claims used to indicate the setting, should reflect the location in which a telehealth service would have normally been provided, had interactions occurred in person. For example, if the member would have come to a private office to receive the service outside of a telehealth modality, a POS 11 would be applied. Providers should not use POS 02 on telehealth claims, even though this POS is referred to as “telehealth” for other payers. Place of service codes can be found at https://www.cms.gov/Medicare/Coding/place-of-service-codes/ Place _of_Service_Code_Set.
Store-and-Forward
Distant site Providers must include the modifier GQ. Place of Service (POS), the two-digit code placed on claims used to indicate the setting, should reflect the location where the distant site provider is located at the time that the service is rendered.
Originating Site Fee
Telemedicine In the event it is medically necessary for a Provider to be present at the originating site at the time a synchronous telehealth service is delivered, said Provider may bill an originating site fee (via procedure code Q3014) when both of the following conditions are met:
· The Medicaid member is located at a provider office or other location where services can be received (this does not include the member’s residence); and
· The Provider (or the Provider’s designee), is affiliated with the provider office or other location where the Medicaid member is located and attends the encounter with the member. The Provider or designee may be present to assist with initiation of the visit but the presence of the Provider or designee in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.
Reimbursement and Billing for Telehealth Services, Page 3-4:
Telemedicine
Distant site Providers must include the modifier GT on claims for services delivered via telemedicine. Place of Service (POS), the two-digit code placed on claims used to indicate the setting, should reflect the location in which a telehealth service would have normally been provided, had interactions occurred in person. For example, if the member would have come to a private office to receive the service outside of a telehealth modality, a POS 11 would be applied. Providers should not use POS 02 on telehealth claims, even though this POS is referred to as “telehealth” for other payers. Place of service codes can be found at https://www.cms.gov/Medicare/Coding/place-of-service-codes/ Place _of_Service_Code_Set.
Comments/Feedback: All other Third Party Group Health Plans and Medicare require the place of service for Telehealth to be billed as POS 02. If DMAS requires that this be billed using the POS that the service would have normally been provided this will require a significant amount of additional system configuration and set up for Providers and Plans. This will be compounded with the multiple lines of business the MCO plans have that covered Members are enrolled in. They include DSNP, CCC Plus, MED4 and Third Party Group Health Plans. Please consider the allowance or flexibility to use the POS 02 to ensure continuity for all lines of business and plans. With the expanded services covered under the supplement I am not sure the magnitude of what this would entail is understood.
Please consider and allow the use of other modifiers, as opposed to limiting modifiers to GT and GQ. The proposed change will exclude all other telehealth modifiers that are currently being utilized. Third Party, other Group Health Plans and DNSP plans require the use of a different modifier other than GT and GQ.
Please provide clarity to the licensure requirement for unlicensed staff.
"Providers must meet state licensure, registration or certification requirements per their regulatory board with the Virginia Department of Health Professions to provide services residents via telemedicine. Providers shall contact DMAS Provider Enrollment (888-829-5373) or the Medicaid MCOs networks for more information."
LBAs/LABAs are licensed by the Board of Medicine, and that includes supervision of unlicensed staff. My question was specific to the ability of those unlicensed staff to provide telehealth services after the state of emergency is lifted. It was a question that came up early in the Covid flexibilities and were told that yes, they were – just want to be sure of the process going forward.
Many agencies are building its behavioral health work force by hiring license eligible staff and other staff working towards a certification. I see no mention of how billing should be done if a license eligible provider working under the supervision of a licensed credential provider renders telehealth services. I recommend a section be included in the telehealth manual to explain the service delivery of supervisees, to include things such as, would the license provider have to be on the telehealth visit with the supervisee? What modifiers would be used for reimbursement?
Member Choice and Education section: Will consent be required for each telehealth appointment or could a provider have a consent form signed annually. Will providers be allowed to document verbal consent or will we need to obtain a “wet signature” from the client.
According to Table 2, Psychosocial Rehabilitation would be authorized for delivery by telemedicine. The DMAS definition states that Psychosocial Rehabilitation shall be provided at least two or more hours per day to groups of individuals in a nonresidential setting. Please provide guidelines for telehealth delivery.
According to Table 2, Case Management services would be authorized for delivery by telemedicine. Could a telehealth appointment replace the 90-day face-to-face service? Please provide guidelines for telehealth delivery.
Telemedicine:
Telemedicine must not be used when face-to-face services are medically and/or clinically necessary. The distant Provider is responsible for determining that the service meets all requirements and standards of care. Certain types of services that would not be expected to be appropriately delivered via telemedicine include, but are not limited to, those that: are performed in an operating room or while the patient is under anesthesia; require direct visualization or instrumentation of bodily structures; involve sampling of tissue or insertion/removal of medical devices; and/or otherwise require the in-person presence of the patient for any reason.
Clarification:
Do you mean to include services that “require direct visualization or instrumentation of bodily structures” as a standalone statement? This suggests that needing to see edema, for example, might need to be completed in person because it requires visualization. It also suggests that if you want to see range of motion on a knee, for example, it also requires an in person visit. Please modify this language to clarify specifically what needs to be seen in person and consider that visualization is precisely what can be accomplished with video.
Originating Site Fee:
In the event it is medically necessary for a Provider to be present at the originating site at the time a synchronous telehealth service is delivered, said Provider may bill an originating site fee (via procedure code Q3014) when both of the following conditions are met: · The Medicaid member is located at a provider office or other location where services can be received (this does not include the member’s residence); and · The Provider (or the Provider’s designee), is affiliated with the provider office or other location where the Medicaid member is located and attends the encounter with the member. The Provider or designee may be present to assist with initiation of the visit but the presence of the Provider or designee in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.
Clarification:
Traditional telemedicine specifically allowed the rendering of clinical care between a patient and a remote provider. These visits are often facilitated by a nurse at the originating site (with the patient) using peripherals (stethoscope, for example, to transmit real-time heart and lung sounds). Will the need to operate a telemedicine cart and peripherals qualify as “clinical need?” There often is no clinical need for a MD/ACP to be available to provider care to the patient at the originating site; only the need for a nurse to operate the video cart and the peripherals.
Thank You:
We appreciate that you include language that will allow an RHC, FQHC, or IHC to serve as a provider site, not only as an originating site.
Documentation Requirements:
When billing for an originating site, the originating site and distant site Providers must maintain documentation at the originating Provider site and the distant Provider site respectively to substantiate the services provided by each. When the originating site is the member’s residence or other location that cannot bill for an originating site fee, this requirement only applies to documentation at the distant site.
Clarification:
If a single appointment, with a provider at a distant site and a patient at an originating site, is scheduled as a single “Joint Appointment” in an electronic health record, will the recording of that visit, including both the provider and patient site check in, intake, and visit documentation, suffice as documentation for both the provider site and the originating site? In other words, the originating site nurse will be documenting in the single Joint Appointment that is a distant provider’s visit and documentation of record? There is not a separate formal documentation of an interaction at the originating site; only the single visit with components from the distant and originating sites.
Authorized Services:
OTP/OBOT Specific Services *Initial prescriber assessment for … buprenorphine induction allowed via telehealth during the Public Health Emergency.
Clarification:
Strongly advocate that this be allowed beyond the Public Health Emergency. If an in person visit is required, this may prohibit patients seeking the care that is needed because of this requirement.
We would like to extend our appreciation for DMAS’ recognition that telehealth and telemedicine services are beneficial and may increase access to services, particularly through the allowance of various community locations as Originating Sites. Unfortunately, Attachment A provides insufficient detail for providers to move forward with using telehealth to provide Mental Health and Substance Use Disorder services, particularly those that are more intensive than Outpatient therapy and medication management. Specific questions along these lines include:
On a more general level:
Reimbursement and Billing for Telehealth Services, Page 3-4: Telemedicine
Distant site Providers must include the modifier GT on claims for services delivered via telemedicine. Place of Service (POS), the two-digit code placed on claims used to indicate the setting, should reflect the location in which a telehealth service would have normally been provided, had interactions occurred in person: Feedback-other Third Party Payers, Group Health Plans, and Medicare require the place of service for Telehealth to be billed as POS 02. If DMAS requires that this be billed using the POS that the service would “have normally been provided” it will be inconsistent with other payers and require a significant amount of additional system configuration and set up for Providers and Plans. This will be compounded with the multiple lines of business that the MCOs cover, including DSNP, CCC Plus, MED4 and Commercial Products. Please consider the allowance or flexibility to use the POS 02 to ensure continuity for all lines of business and plans.
First of all, the publication of a telehealth supplement is very much appreciated. This is much better information than the limited information in the Provider Memo issued in 2014.
Would recommend that 'telemedicine' be replaced with 'telehealth' As this provides a more global and generic reference for these services. Also, please consider including audio only as an option for behavioral health services. There is a need for audio only services in several areas of the State where rural and lower income clients lack access to internet services. these are needed se4rvices that would both reduce barriers and increase access to these needed services. This is especially important for early intervention and crisis services as well as for the coordination of care. This would also serve to reduce transportation barriers for needed services.
The telehealth supplement and additional guidance is much appreciated. Thank you.
Page 11: Concern with the wording of two elements listed as requirements under Care Coordination Requirements of Mental Health Providers
I recommend deleting "trained facilitator" from the list of options for persons present during Early Intervention services. A "trained facilitator" is not part of the Part C Early Intervention cadre of personnel.
What actions will DMAS take to ensure standardization across the various contracted MCOs for the expectations in the provision of telehealth/telemedicine services?