New York State Medicaid Coverage of Telehealth
This is an outdated page. For current information please see our most recent guidance
April 2019
Telehealth Expansion
- Telehealth is defined as the use of electronic information and communication technologies to deliver health care to patients at a distance.
- Originating Site: Where the member is located at the time health care services are delivered.
- Distant Site: Any secure location where the telehealth provider is located while delivering health care services by means of telehealth.
- A Special Edition Medicaid Update was issued in February 2019.
- The expanded telehealth policy is effective January 1, 2019 for Medicaid fee–for–service (FFS) and March 1, 2019 for Medicaid Managed Care (MMC).
- Nothing precludes implementation by the MMC Plans prior to January 1, 2019.
- Pursuant to New York State (NYS) Public Health Law (PHL) Article 29–G, as recently amended, and Social Services Law (SSL) Section 367–u, NYS Medicaid has expanded coverage of telehealth services to include:
- additional originating and distant sites;
- additional practitioner–types; and
- additional telehealth applications (store and forward technology, and remote patient monitoring)
| Medicaid Reimbursement Policy as of March 2015 | Modalities, Originating Sites and Distant Sites Have Been Expanded and Include the Following (in addition to those listed in Column One) | |
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| Eligible Modalities |
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| Eligible "Originating" Sites (Location of Patient) |
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| Eligible "Distant" Sites (Location of Consulting Practitioner) |
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| Eligible Telehealth Practitioner–Types |
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Telehealth Practitioner Requirements
- Practitioners providing services via telehealth must be licensed or certified, currently registered in accordance with NYS Education Law or other applicable law, and enrolled in NYS Medicaid.
- Telehealth services must be delivered by providers acting within their scope of practice.
- Reimbursement will be made in accordance with existing Medicaid policy related to supervision and billing rules and requirements.
- Providers must be credentialed at both the distant site and the originating site in order to provide telehealth services.
Credentialing and Privileging
- The Article 28 hospital acting as an originating site may rely on the credentialing and privileging decisions of the distant site hospital when granting or renewing privileges to a health care practitioner who is a member of the clinical staff at the distant site hospital.
- The distant site hospital collects and evaluates all credentialing information and performs all required verification activities, and acts on behalf of the originating site hospital for such credentialing purposes.
- The distant site reviews (at least every two years) the credentials, privileges, physical and mental capacity and competence of the telehealth provider and reports the results of the review to the originating site.
- The originating site also reviews (at least every two years) the performance of these privileges and provides the distant site hospital with the performance evaluation for use in the distant site´s periodic appraisal of the telemedicine practitioner.
Confidentiality
- All services must be performed on dedicated secure transmission linkages that meet the minimum federal and state requirements.
- HIPAA requires that a written “business associate agreement” (BAA) or contract that provides for privacy and security of protected health information be in place between the telehealth provider and the supporting telehealth vendor.
- All confidentiality requirements that apply to medical records apply to services delivered by means of telehealth.
- The medical record must document the physical location of the patient as well as the physical location of the distant site practitioner.
Consent
- Providers must document in the medical record that the Medicaid member has consented to the six questions under Part E of the February 2019 Medicaid Update on telehealth.
- Providers must have written protocols and procedures on how practitioners shall provide the Medicaid member with basic information about the services they will be receiving via telehealth and the member shall provide their consent to participate in services utilizing this technology.
Failure to Transmission
- All telehealth providers must have a written procedure detailing a contingency plan in the case of a failure of transmission or other technical difficulty that renders the service undeliverable via telehealth.
- Policies and procedures must be available upon audit.
- If the service is undelivered due to a failure of transmission or other technical difficulty, a claim should not be submitted to Medicaid.
Modifiers
To Be Used When Billing for Telehealth Services
| Modifier | Description | Note/Example |
|---|---|---|
| 95 | Synchronous telemedicine service rendered via real–time interactive audio and video telecommunication system | Note: Modifier 95 may only be appended to the specific services covered by Medicaid and listed in Appendix P of the AMA´s CPT Professional Edition 2018 Codebook. The CPT codes listed in Appendix P are for services that are typically performed face–to–face but may be rendered via a real–time (synchronous) interactive audio–visual telecommunication system. |
| GT | Via interactive audio and video telecommunication systems | Note: Modifier GT is only for use with those services provided via synchronous telemedicine for which modifier 95 cannot be used. |
| GQ | Via asynchronous telecommunications system | Note: Modifier GQ is for use with Store and Forward technology |
| 25 | Significant, separately identifiable evaluation & management (E&M) service by the same physician or other qualified health care professional on the same day as a procedure or other service | Example: The member has a psychiatric consultation via telemedicine on the same day as a primary care E&M service at the originating site. The E&M service should be appended with the 25 modifier. |
Place of Service Code
To Be Used When Billing for Telehealth Services
| POS Code | Description |
|---|---|
| 2 | The location where health services and health related services are provided or received, through telehealth telecommunication technology. When billing telehealth services, providers must bill with place of service code 02 and continue to bill modifier 95, GT or GQ. |
Billing Rules for Telehealth Services
- Only one clinic payment will be made when both the originating site and the distant site are part of the same provider network/billing entity. In such cases, only the originating site should bill Medicaid for the telemedicine encounter.
Fee–for–Service (FFS)
Billing Rules for Telehealth Services
Article 28 Clinic Originating Sites Billing Under Ambulatory Patient Groups (APGs)
– Institutional Component
- Telehealth encounter only – bill Q3014 (telehealth originating–site facility fee) through APGs to recoup administrative expenses associated with the telemedicine encounter.
- Telehealth encounter & separate and distinct service – bill for the medical service provided (append with modifier 25) in addition to Q3014. The CPT code billed for the separate and distinct service must be appended with the 25 modifier.
– Professional Component
- Physician Onsite– A physician claim cannot be billed to Medicaid if the physician is onsite at the Article 28 hospital and is only assisting or attending the member during a telemedicine encounter.
- Telehealth encounter & separate and distinct service – The physician may bill for the medical service provided. The CPT code billed for the separate and distinct service must be appended with the 25 modifier. All non–physicians are included in the APG payment to the originating–site facility.
Article 28 Clinic Distant Sites Billing Under Ambulatory Patient Groups (APGs)
– Institutional Component
- Distant–site practitioner is physically onsite at the Article 28 – the distant site may bill Medicaid under APGs for the telemedicine encounter using the appropriate CPT code for the service provided. The CPT code must be modified with the applicable modifier (95 or GT).
– Professional Component
- Distant site practitioner is an Article 28 hospital department/clinic and telemedicine services are provided by a physician– the physician should bill Medicaid using the appropriate CPT code for the service provided appended with the applicable modifier (95).
- Distant site practitioner is an Article 28 hospital department/clinic and telemedicine services are provided by a non–physician– The professional component is included in the APG payment to the facility.
Office Setting or Other Secure Location (Originating Site)
– Professional Component
- Telemedicine encounter only – The originating–site practitioner may bill CPT code Q3014 to recoup administrative expenses associated with the telemedicine encounter.
- Telemedicine encounter & separate and distinct service – The originating–site practitioner may bill for the separate and distinct medical service unrelated to the telemedicine encounter provided in addition to Q3014. The CPT code billed for the separate and distinct medical service must be appended with the 25 modifier.
Office Setting or Other Secure Location (Distant Site)
– Professional Component
- If the distant–site practitioner is providing services via telemedicine from their private office or other secure location, the practitioner should bill the appropriate CPT code for the service provided. The CPT code should be appended with the applicable modifier (95 or GT).
Inpatient Hospital as Originating Site
- When a telemedicine consult is being provided by a distant–site physician to a Medicaid member who is an inpatient in the hospital, payment for the telemedicine encounter may be billed by the distant–site physician.
- Other than physician services, all other practitioner services (NP, PA, etc.) are included in the APR–DRG payment to the facility.
Skilled Nursing Facilities (SNFs) as Originating Sites
- Determining whether telehealth services are in or out of the nursing home´s rate is the responsibility of the telehealth practitioner.
- 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 bill should be appended with the applicable modifier (95 or GT).
Federally Qualified Health Centers (FQHCs)
- FQHCs that have "opted into" APGs should follow the billing guidance provided for sites billing under APGs.
- FQHCs that have not opted into APGs:
- Telehealth encounter only – bill the FQHC offsite services rate code (4012) to recoup administrative expenses associated with the telemedicine encounter.
- Telehealth encounter & separate and distinct service – bill the Prospective Payment System (PPS) rate in addition to the FQHC offsite services rate code (4012). Append the CPT code with the 25 modifier.
- When providing services via telemedicine to a member who is in their place of residence or other temporary location, the FQHC should bill the FQHC off–site services rate code (4012).
Store and Forward Technology
- Reimbursement will be made to the consulting distant–site practitioner.
- Reimbursement for consultations provided via store and forward technology will be paid at 75 percent of the Medicaid fee for the service provided.
- The consulting practitioner should bill the CPT code for the professional service appended with the telehealth modifier "GQ".
Remote Patient Monitoring (RPM)
- 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).
- A fee of $48.00 per month will be paid for RPM. To bill for RPM, a minimum of 30 minutes per month must be spent collecting and interpreting the member's RPM data.
- Providers are not to bill 99091 more than one time per member per month.
- Providers should bill for RPM services on the last day of each month in which RPM is in use.
- FQHCs that have opted out of APGs are unable to bill for RPM services at this time.
Medicare/Medicaid Dual Eligible Beneficiaries
- If Medicare covers the telehealth encounter, Medicaid will reimburse the Part B coinsurance and deductible to the extent permitted by state law.
- If the service is outside of the geographic region recognized by Medicare and they deny coverage of the telehealth encounter, Medicaid will not cover such services.
- If the service provided is one that is not within the scope of services covered by Medicare (e.g. CASACs, dental, store–and–forward) but is an eligible telehealth service under Medicaid, the telehealth encounter may be billed to Medicaid.
Medicaid Managed Care
Medicaid Managed Care Considerations
- Medicaid Managed Care (MMC) Plans are required to cover, at a minimum, services that are covered by Medicaid fee–for–service in addition to services included in the MMC benefit package, when determined medically necessary.
- Questions regarding MMC reimbursement and/or billing requirements should be directed to the member's MMC plan.
Questions
- Questions regarding Medicaid FFS billing, should be directed to eMedNY Provider Services at (800) 343–9000.
- Policy questions regarding Medicaid FFS may be directed to the Office of Health Insurance Programs, Division of Program Development and Management at (518) 473– 2160.
- Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan.
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