This document summarizes existing and new coverage. New coverage includes:
- A new Health Evidence Review Commission (HERC) guideline clarifying expanded coverage of synchronous audio and video, online (e.g. patient portal) services and provider-to-provider consultations for physical and behavioral health (Guideline Note A5).
- Fee-for-service Medicaid is opening additional codes to payments:
- telephone service evaluation/assessment and management codes for behavioral health providers (retroactive to January 1, 2020)
- synchronous audio/video visits, online (e.g. patient portal) services and provider-to- provider consultations for physical health providers
- CCOs shall cover telemedicine services identified in HERC guideline note A5 effective March 13, 2020, but OHA encourages CCOs to make this coverage retroactive to January 1, 2020.
- OAR 410-130-0610 rule language is being revised and vetted through OHA to remove barriers to telemedicine services. A link to the new rule will be provided when published.
- OAR 410-146-0085 and 410-147-0120 rule language is being revised to clarify telemedicine encounters for FQHCs and RHCs. A link to the new rule will be provided when published.
- Fee-for-service Medicaid changes are pending claims system configuration. Please allow up to one week to MMIS changes to take effect.
- OHA is actively looking into ways to allow additional services to be provided so that members can access important services for physical and behavioral health.
Telemedicine/telehealth (e.g. video and patient portal)
What is telemedicine/telehealth?
Telemedicine or telehealth services are health care services rendered to patients using electronic communications such as secure email, patient portals and online audio/video conferencing.
Does the Oregon Health Plan cover telemedicine services?
To be eligible for coverage, telemedicine services must comply with:
- Oregon Administrative Rules (OAR) 410-120-1200 (excluded services and limitations),
- OAR 410-130-0610 (Telemedicine). This rule is being updated and will be linked to this communication when published with the Secretary of State.
- OAR 410-172-0850 (Telemedicine for behavioral health) and
- Guideline Note A5 (Teleconsultations and non-face-to-face telehealth services) from the Prioritized List of Health Services. This guideline note was updated March 13, 2020.
Does the Oregon Health Plan cover telephone services?
Yes. Telephone calls can be billed for the following services:
- 99441-99443 for providers who can provide evaluation and management services;
- 98966-98968 for other types of providers, including nonphysician behavioral health providers
What about CCOs? Does OHA allow CCOs to cover telehealth and telemedicine services?
Yes, subject to Guideline Note A5 for services that are already covered for in-person visits, such as:
- Evaluation and management services (for providers who can perform these services, such as physicians, physician assistants or nurse practitioners), or
- Assessment and management services (for other types of providers including behavioral health providers and dietitians).
- Consultations between providers in a variety of settings (by telephone or other electronic forms of communication)
This is true for both physical health and behavioral health services. CCO contracts require CCOs to ensure that telemedicine credentialing requirements are consistent with OAR 410-130-0610(5).
Can I provide telephone/telemedicine services to a CCO member?
Yes. If the service falls under those described in Guideline Note A5 in the HERC guidelines. CCOs may cover additional telephone/telemedicine services. Contact the patient’s CCO for specific guidance on their telephone/telemedicine/telehealth services and policies.
What telephone/telemedicine codes are covered for physical health services?
- Audio/video telemedicine services with synchronous audio and video, regardless of the location of the patient (inpatient, outpatient or community) using ordinary evaluation and management codes. For instance, 99201-99215 are covered. See HERC Guideline Note Guideline Note A5 (Teleconsultations and non-face-to-face telehealth services) for a list of services that can be covered
- Online services (e.g. electronic patient portals). CPT codes include 99421-99423 for physicians, 98970-98972 for non-physicians who can bill evaluation and management services, and G2061-G2063 for assessment and management services by other provider types.
- CPT 99451-99452 and 99446-99449 are available for provider-to-provider consultations.
- Telephone services (CPT codes include 99441-99443 for providers who can provide evaluation and management services; 98966-98968 for other types of providers, including nonphysician behavioral health providers)
Some of these codes have other limitations, such as being only for established patients and not being related to an in-person visit. See industry coding resources for details. Online communications must by encrypted (HIPAA-compliant).
What codes are covered for behavioral health providers? Telemedicine services (synchronous audio and video)
The fee-for service behavioral health fee schedule lists all codes that include telemedicine reimbursement when billed with modifier GT. These services have been covered for several years. These codes include:
- Psychotherapy, Mental health assessmentsand
To be eligible for telemedicine reimbursement, the services must be provided using a synchronous audio-video platform compliant with HIPAA and 42 CFR part 2. Reimbursement will be the same as for services provided in-person.
Telephone services (99441-99433, 98966-98968) are new codes for behavioral health providers during the COVID-19 crisis and will be configured in MMIS by Tuesday, March 17, 2020.
These codes are newly eligible for payment (retroactive to January 1, 2020) when the service is:
Provided by a qualified nonphysician health care professional to an established patient, parent, orguardian,
Not related to an assessment and management service provided within the previous 7days,
Not related to an assessment and management service or procedure scheduled to occur within the next 24 hours or soonest availableappointment.
If there is a related visit, billing for that visit should suffice.
As part of the COVID-19 crisis, OHA is investigating ways to allow behavioral health providers to provide services via telephone. Additional guidance will be forthcoming as we receive approval from Federal Medicaid (CMS).