COVID-19 Client Resources and Updates

Telehealth has emerged as an important tool in the battle against COVID-19. By allowing health care providers to care for patients so that neither provider nor patient must leave their homes, telehealth facilitates the provision of essential health care services without risking further community spread of the virus. The Trump administration has made significant changes to the Medicare telehealth rules as described here and here. In Connecticut, Governor Lamont similarly expanded the permissible scope of telehealth in the state through Executive Orders. In addition, the Connecticut Department of Social Services (“DSS”) made several changes to the Connecticut Medical Assistance Program to expand coverage of telehealth services.  

Governor Lamont’s Executive Orders

On March 18, 2020, Governor Lamont issued Executive Order No. 7F, authorizing the Commissioner of Social Services to temporarily waive any state law restrictions as necessary to enable Medicaid to cover audio-only telehealth services.

The next day, on March 19, 2020, the Governor issued Executive Order No. 7G, making the following changes to Connecticut General Statutes section 19a-906 and any associated regulations, rules, and policies regarding delivery of telehealth:

• The statute specifically excludes “audio-only telephone” from the definition of telehealth. The Executive Order removes this exclusion for: (1) telehealth providers that are Medicaid enrolled providers providing covered telehealth services to established patients who are Medicaid beneficiaries and (2) telehealth providers that are in-network providers for commercial fully-insured health insurance providing covered telehealth services to patients with whom there is an existing provider-patient relationship.
• The existing statute provides a list of licensed practitioners who may qualify as a “telehealth provider.” The Executive Order states that the statute’s requirements for licensure, certification, or registration of telehealth providers “shall be suspended” for telehealth providers that are Medicaid enrolled providers or in-network providers for commercial fully-insured health insurance providing telehealth services to patients, but only “in accordance with any related orders issued by the Commissioner of Public Health.” To date, the Connecticut Department of Public Health has not issued any such orders.
• The Executive Order modifies the statute’s requirement that the provision of telehealth services and the health records maintained as part of a telehealth interaction comply with HIPAA. Instead, the Executive Order requires that telehealth providers utilize “information and communication technologies consistent and in accordance with any direction, modification or revision of requirements for HIPAA compliance as related to telehealth remote communications as directed by the United States Department of Health and Human Services, Office of Civil Rights during the COVID-19 pandemic.” In this section of the Executive Order, the Governor seeks to incorporate the recent announcement by the Office for Civil Rights (“OCR”), the federal agency that enforces HIPAA, that during the COVID-19 nationwide public health emergency, penalties for HIPAA violations will be waived for “health care providers that serve patients in good faith through everyday communications technologies,” such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype.
• The Executive Order implements payment rules regarding the provision of telehealth to patients who do not have Medicaid coverage and are not covered by a fully-insured commercial plan. The Executive Order states that a provider who elects to provide telehealth services to such patients must first determine whether the patient is covered by a health plan that provides coverage for telehealth services. Providers who receive payment under such a health plan are prohibited from billing the patient for any additional charges beyond the reimbursement received from the health plan. If the provider determines that payment is not available, the provider must accept the amount that Medicare reimburses for the service as payment in full. If the provider determines that the patient is uninsured or otherwise unable to pay for such services, the provider must offer financial assistance, if the provider is otherwise required to provide financial assistance under state or federal law.
• The Executive Order waives “any related regulatory requirement” that telehealth services be provided from a provider’s licensed facility. Providers are permitted to provide telehealth from any location.

These Executive Orders represent great strides towards expanding telehealth services in Connecticut and have opened new avenues for Medicaid reimbursement of many services via telehealth during the COVID-19 crisis, as described further below.

Connecticut Medicaid Telehealth Changes

DSS has made sweeping changes to Medicaid coverage for telemedicine services in response to the COVID-19 pandemic. Outlined in a series of Policy Bulletins, these changes apply to a wide range of services, but also impose specific limitations and requirements.

The first Policy Bulletin expanding Medicaid coverage of telemedicine services was issued on March 11, 2020 when DSS announced in Provider Bulletin 2020-09 that effective March 13, 2020, a limited number of telehealth services will be covered under the Connecticut Medical Assistance Program. On that same day, DSS issued Policy Bulletin 2020-10 temporarily expanding portions of its telemedicine coverage until the state has deemed COVID-19 to no longer be a public health emergency.

Pursuant to its new telemedicine policy, DSS stated that it only covers synchronous telemedicine with an audio and video telecommunication system and real-time communication between the patient and practitioner. However, audio-only telephone interaction is additionally temporarily covered for select evaluation and management services and behavioral health services rendered to established patients, as described further below.

At first, DSS mandated that only HIPAA compliant software be used to facilitate telehealth services, but in later Policy Bulletins DSS recognized that the Office for Civil Rights (“OCR”), the federal agency that enforces HIPAA, has waived penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies.” DSS stated that it “still recommends that, whenever possible, providers should fully comply with all details of HIPAA privacy and security rule provisions as written in order to best safeguard the privacy and security of protected health information.” DSS further prohibited providers from saving recordings of telehealth video conferencing sessions.

Heightened informed consent requirements are required for Medicaid telehealth services. Providers must explicitly obtain informed consent from each patient before providing telehealth services and annually thereafter. Moreover, the provider must ensure that each patient “is aware they can opt-out or refuse telehealth services at any time.” Informed consent must be fully documented in the medical record. When written consent cannot be obtained, DSS permits providers to obtain verbal consent. If the member is a minor child, a parent or legal guardian must provide verbal informed consent before providing services via the telephone. Providers must develop and implement procedures to verify provider and patient identity.

DSS reminded providers that all requirements that would otherwise apply to the same service if performed face-to-face are still applicable, including medical necessity, enrollment, scope of practice, licensure, and documentation. If technical difficulties prevent the services from being provided or completed, no claim should be submitted. Unlike traditional Medicare telehealth rules, Medicaid placed no restriction on the location of the patient at the time of the service. Patients may receive telemedicine services pursuant to the policy, even while they are at home.

The following is a summary of the Medicaid telehealth covered services announced to date. Providers should consult with the applicable Policy Bulletins for a full understanding of all service limitations and coding requirements.

1. Psychotherapy and Psychiatric Diagnostic Evaluation

The telemedicine expansion applies to the following CPT codes for individual and family psychotherapy and psychiatric diagnostic evaluation:

• 90832: Psytx pt &/family: 30 minutes
• 90833: Psytx pt &/fam w/e&m: 30 minutes
• 90834: Psytx pt &/family: 45 minutes
• 90836: Psytx pt &/fam w/e&m: 45 minutes
• 90837: Psytx pt &/family 60 minutes
• 90838: Psytx pt &/fam w/e&m: 60 minutes
• 90847: Family psytx w/patient
• 90791: Psych diag eval
• 90792: Psych diag eval w/E&M

Psychiatric diagnostic evaluations are permitted only when the patient is located at a Medicaid-enrolled originating site location, like a health care office/facility. Note, however, that this requirement is waived during the COVID-19 public health emergency.

Only the following clinicians are authorized to provide psychotherapy services and psychiatric diagnostic evaluations via telemedicine:

• Physicians
• Physician Assistants (PAs)
• Advanced Practice Registered Nurses (APRNs)
• Licensed Behavioral Health Clinicians (Licensed Psychologists, Licensed Clinical Social Workers, Licensed Marital and Family Therapists, Licensed Professional Counselors, and Licensed Alcohol and Drug Counselors)
• Behavioral Health Clinics – including Enhanced Care Clinics (ECCs)
• Behavioral Health Federally Qualified Health Centers (FQHCs)
• Medical Clinics – excluding School Based Health Centers (SBHCs)
• Rehabilitation Clinics
• Outpatient Hospital Behavioral Health (BH) Clinics
• Outpatient Psychiatric Hospitals
• Outpatient Chronic Disease Hospitals (CDHs)

In Policy Bulletin 2020-14, DSS announced that effective March 18, 2020 and until otherwise notified by DSS in writing, the following audio-only CPT codes can be billed for behavioral health services:

• 98967: Telephone assessment and management service, 11-20 minutes of medical discussion (to be used for BH services outlined above rendered via telephone)
• 98968: Telephone assessment and management service, 21-30 minutes of medical discussion (to be used for BH services outlined above rendered via telephone)

Only one unit of each of these codes may be billed, but they may be billed together on the same date of service for the same patient by the same provider if the duration of the telephone call exceeds 41 minutes.

2. Medication Assisted Treatment

Certain medication assisted treatment services are also included in the telehealth Medicaid expansion. Methadone maintenance clinics may perform physical evaluations that are required prior to admission via telehealth if (1) the patient is located in another Medicaid-enrolled methadone maintenance clinic that is part of the same billing entity as the originating site; (2) the originating site is providing all the other required components of medication assisted treatment services, including the intake and psychiatric evaluation; (3) an authorized health care professional under the supervision of a program physician is present with the member at the originating site; and (4) the distant site provider is located at a different service location/address than the originating site. Office based opioid treatment providers may also provide medication management and psychotherapy services via telehealth, but such services may only be provided by physicians, APRNs, PAs, and behavioral health clinics.

Although DSS originally excluded induction services from the telehealth expansion, in Policy Bulletin 2020-14, DSS stated that effective March 18, 2020, opioid treatment programs can fulfill the face-to-face requirement with a physician, APRN or PA seeing the individual via telemedicine as part of the induction services, as long as there is an RN in the same location as the individual when the telemedicine service is initiated and the qualified health care professional and the physician, APRN or PA are employed by the same opioid treatment program.

3. Medication Management Services

DSS permits the following CPT codes to be provided via telehealth for medication management services:

• 99211: Office/outpatient visit est
• 99212: Office/outpatient visit est
• 99213: Office/outpatient visit est
• 99214: Office/outpatient visit est
• 99215: Office/outpatient visit est

These services are covered when provided via telehealth only when rendered by physicians, PAs, APRNs, medical clinics, behavioral health clinics, behavioral health FQHCs, outpatient hospital behavioral health clinics, or outpatient chronic disease hospitals.

4. Pre- and Post-Surgery Consultations

In cases where DSS approved an out-of-state surgery for a Medicaid patient, the patient may receive pre- or post-surgical consultations via telemedicine.

5. Medical Services

The following medical services CPT codes were approved to be provided via telehealth:

• 90791: Psych diag eval
• 90792: Psych diag eval w/E&M
• 90832: Psychotherapy: 30 minutes
• 90833: Psychotherapy w/e&m: 30 minutes
• 90834: Psychotherapy: 45 minutes
• 90836: Psychotherapy w/e&m: 45 minutes
• 90837: Psychotherapy: 60 minutes
• 90838: Psychotherapy w/e&m: 60 minutes
• 90847: Family psytx w/patient
• 99211: Office/outpatient visit est
• 99212: Office/outpatient visit est
• 99213: Office/outpatient visit est
• 99214: Office/outpatient visit est
• 99215: Office/outpatient visit est
• 99201-99205: Office/outpatient visit new (only permitted via telehealth during the COVID-19 publicly declared emergency)

Generally, these services are only permitted to be provided via telehealth if the patient is certified to be homebound, however DSS temporarily waived that requirement during the COVID-19 publicly declared emergency. Also, these services generally must be provided via synchronous telemedicine (audio and video telecommunication system with real-time communication between the patient and practitioner), however, in Policy Bulletin 2020-14, DSS announced that effective March 18, 2020 and until otherwise notified by DSS in writing, the following evaluation and management services may be provided via audio-only telehealth to established patients:

• 99442: Physician telephone patient service, 11-20 minutes of medical discussion
• 99443: Physician telephone patient service, 21-30 minutes of medical discussion

These audio-only CPT codes may be billed only once per day per patient and may be provided only by physicians, APRNs, PAs, CNMs, free-standing medical clinics (not school-based health centers), behavioral health clinics (including enhanced care clinics), outpatient hospital behavioral health clinics, public and private psychiatric outpatient hospital clinics, federally qualified health centers (FQHCs), and family planning clinics.

6. Physical Therapy, Occupational Therapy, and Speech and Language Pathology

On March 20, 2020, Policy Bulletin 2020-23 and Policy Bulletin 2020-24 were issued, providing expanded reimbursement for telemedicine to cover physical therapy, occupational therapy, and speech and language pathology services. Effective March 20, 2020 for the duration of the COVID-19 public health emergency for established patients only, certain therapy services may be covered by Medicaid when provided via telemedicine.

In a rehabilitation clinic, the following services are covered:

• 97010: Hot or cold packs therapy
• 97012: Mechanical traction therapy
• 97014: Electric stim therapy
• 97016: Vasopneumatic device therapy
• 97022: Whirlpool therapy
• 97110: Therapeutic exercises
• 97112: Neuromuscular reeducation
• 97113: Aquatic therapy/exercises
• 97129: Ther ivntj 1st 15 min
• 97130: Ther ivntj ea addl 15 min
• 97533: Sensory Integration
• 92507: Treatment of speech, language, voice, comm., and/or hearing processing disorder
• 92521: Evaluation of speech fluency
• 92522: Evaluation of speech sound production
• 92523: Evaluation of speech sound production w/ evaluation of language comp

For independent physical therapy/occupation therapy providers, the following services are covered:

• 97010: Hot or cold packs therapy
• 97012: Mechanical traction therapy
• 97014: Electric stim therapy
• 97016: Vasopneumatic device therapy
• 97018: Paraffin bath therapy
• 97022: Whirlpool therapy
• 97110: Therapeutic exercises
• 97112: Neuromuscular reeducation
• 97113: Aquatic therapy/exercises
• 97129: Ther ivntj, first 15 minutes
• 97130: Ther ivntj, each additional 15 minutes

For speech and language pathology services, the following services are covered:

• 92507: Treatment of speech, language, voice, comm., and/or hearing processing disorder
• 92521: Evaluation of speech fluency
• 92522: Evaluation of speech sound production
• 92523: Evaluation of speech sound production w/ evaluation of language comprehension

In the outpatient hospital setting, physical therapy, occupational therapy, and speech language pathology services may be rendered via telemedicine and are paid as an all-inclusive rate to the hospital. Professional services are not be permitted to be billed separately. The following CPT codes are authorized:

• 96125: Standardized cognitive performance testing
• 97010: Hot or cold packs therapy
• 97012: Mechanical traction therapy
• 97014: Electric stim therapy
• 97016: Vasopneumatic device therapy
• 97018: Paraffin bath therapy
• 97022: Whirlpool therapy
• 97110: Therapeutic exercises
• 97112: Neuromuscular reeducation
• 97113: Aquatic therapy/exercises
• 97129: Ther ivntj, first 15 minutes
• 97130: Ther ivntj, each additional 15 minutes
• 97533: Sensory integrative techniques
• 92507: Treatment of speech, language, voice, comm., and/or hearing processing disorder
• 92521: Evaluation of speech fluency
• 92522: Evaluation of speech sound production
• 92523: Evaluation of speech sound production w/ evaluation of language comprehension and expression

Notably missing from these lists are evaluations, reevaluations, and group therapy services which are not currently Medicaid covered when provided via telehealth. Also, Medicaid opted not to extend telehealth coverage to audiology services at this time.

7. Group Therapy Services

On March 23, 2020, DSS issued Policy Bulletin 2020-25 further expanding telemedicine to cover specified group therapy services. This expansion is effective March 23, 2020 for the duration of the COVID-19 public health emergency. DSS explicitly stated that in instances where members are required to sign initial and updated treatment plans or plans of care, verbal consent will be permitted so long as it is documented. Also, group psychotherapy is only reimbursable for patients who have already completed a psychiatric diagnostic evaluation, been admitted to treatment, and have been determined to need group psychotherapy. Group psychotherapy provided via telemedicine must be conducted in a private setting and the members must be advised about privacy precautions.

The following CPT codes are now permitted to be performed by behavioral health clinics and clinicians via telemedicine:

• 90853: Group Therapy
• 90849: Multi-family Group Psychotherapy
• S9480: Intensive Outpatient Program – Psychiatric
• H0015; Intensive Outpatient Program – Chemical Dependency
• H0035: Partial Hospitalization Program
• H2013: Adult Day Treatment

Outpatient hospitals are authorized to provide the following telemedicine group therapy services so long as providers render only services within their applicable scopes of practice:

• RCC 915 (Procedure Code 90853): Group Therapy
• RCC 916 (Procedure Code 90849): Multi-family Group Psychotherapy
• RCC 905 (Procedure Code S9480): Intensive Outpatient Program – Psychiatric
• RCC 906 (Procedure Code H0015): Intensive Outpatient Program – Chemical Dependency
• RCC 913 (Procedure Code H0035): Partial Hospitalization

8. Autism Spectrum Services

Policy Bulletin 2020-25 also provides for coverage of autism spectrum services (ASD) provided via telehealth (H0046: Direct Observation and Direction). The service must be provided by a licensed practitioner either when a technician is delivering treatment services in the home of a member or when the member, the technician, and the licensed practitioner are “simultaneously using the same telemedicine platform to deliver the ASD treatment service and observe the technician providing the ASD treatment services.”

9. Home Health Agencies, Access Agencies, and Hospice Agencies

On April 1, 2020, DSS issued Policy Bulletin 2020-28 announcing that effective March 27, 2020 for the duration of the COVID-19 public health emergency, specified home health and hospice services provided via telehealth will be covered by the Medicaid program. Initial evaluations for start of care and subsequent re-certifications of resumption of care for medical and behavioral health services (including for all therapy services) must continue to be provided in-person and may not be provided by telemedicine.

For medication administration services, the following non-waiver home health services can be rendered via synchronized telemedicine or telephonically:

• RCC 580 (HCPCS T1502): Admin of oral intramuscular and/or subcutaneous medication, per visit
• RCC 580 (HCPCS Code T1503): Admin of medication, other than oral and/or injectable, per visit

Although these codes are for direct face-to-face administration of medication, DSS will allow their use when the home health nurse pre-pours the patient’s oral medications ahead of time and then uses telemedicine to conduct a brief assessment and to prompt patients to take their already pre-poured medications.

For therapy services, the following non-waiver home health therapy services may be rendered via audio-visual telemedicine only (audio-only telephone is not permitted for these services):

• RCC 421: Physical Therapy
• RCC 431: Occupational Therapy
• RCC 441: Speech Pathology

Face-to-face visits with an enrolled provider are also eligible to be performed via audio-visual telemedicine (not audio-only).

DSS also announced waivers of certain requirements. For example, the Policy Bulletin states that the requirement that recertifications of start of care or resumption of care must be completed within a 60 day window will be waived and that EVV will be suspended for select therapy services and medication administration services.

For hospice services, hospice agencies will be permitted to provide services via telemedicine or audio-only telephone, so long as all other applicable requirements are met for the services. The hospice agency is required to document any services rendered via telemedicine or telephonically.

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Visit Wiggin and Dana’s COVID-19 Resource Center here for additional publications and helpful links on multi-disciplinary topics that are relevant during the current COVID-19 global pandemic.