907 KAR 3:170. Telehealth consultation coverage and reimbursement.

907 KAR 3:170. Telehealth consultation coverage and reimbursement.

RELATES TO: KRS 12, 205.510(15), 194A.060, 194A.125, 205.559, 205.560, 422.317, 434.840-434.860, 42 C.F.R. 415.174, 415.184, 431.300-431.307, 440.50

STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.559(2), (7), 205.560

NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed or opportunity presented by federal law for the provision of medical assistance to Kentucky's indigent citizenry. KRS 205.559 establishes the requirements regarding Medicaid reimbursement of telehealth providers and KRS 205.559(2) and (7) require the cabinet to promulgate an administrative regulation relating to telehealth consultations and reimbursement. This administrative regulation establishes the Department for Medicaid Services' coverage and reimbursement provisions relating to telehealth consultations in accordance with KRS 205.559.

Section 1. Definitions. (1) "Advanced registered nurse practitioner" or "ARNP" is defined by KRS 314.011(7).

(2) "Certified nutritionist" is defined by KRS 310.005(12).

(3) "Chiropractor" is defined by KRS 312.015(3).

(4) "Community mental health center" or "CMHC" means a facility that provides a comprehensive range of mental health services to Medicaid recipients of a designated area in accordance with KRS 210.370 to 210.485.

(5) "CPT code" means a code used for reporting procedures and services performed by physicians or other licensed medical professionals which is published annually by the American Medical Association in Current Procedural Terminology.

(6) "Department" means the Department for Medicaid Services or its designated agent.

(7) "Diabetes self-management education" means the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care.

(8) "Dietitian" is defined by KRS 310.005(3).

(9) "Encounter" means one (1) visit by a recipient to a telehealth spoke site where the recipient receives a telehealth consultation in real time, during the visit, from a provider at a telehealth hub site.

(10) "Federal financial participation" is defined in 42 C.F.R. 400.203.

(11) "GT modifier" means a modifier that identifies a telehealth consultation which is approved by the healthcare common procedure coding system (HCPCS).

(12) "Health care common procedure coding system" or "HCPCS" means a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).

(13) "Health care provider" means a Medicaid-enrolled provider, in accordance with 907 KAR 1:671 and 907 KAR 1:672, who is a:

(a) Licensed physician;

(b) Licensed advanced registered nurse practitioner;

(d) Licensed dentist or oral surgeon;

(e) Community mental health center;

(f) Psychologist with a license in accordance with KRS 319.010(5);

(g) Licensed clinical social worker;

(h) Chiropractor; or

(i) Licensed optometrist.

(14) "Hub site" means a telehealth site:

(a) Where the telehealth provider performs telehealth; and

(b) That is considered the place of service.

(15) "KenPAC" means the Kentucky Patient Access and Care System.

(16) "KenPAC PCCM" means a Medicaid provider who is enrolled as a primary care case manager in the Kentucky Patient Access and Care System.

(17) "Legally-authorized representative" means a Medicaid recipient's parent or guardian if a recipient is a minor child, or a person with power of attorney for a recipient.

(18) "Licensed clinical social worker" means an individual meeting the licensure requirements established in KRS 335.100.

(19) "Licensed dietitian" is defined by KRS 310.005(11).

(20) "Licensed marriage and family therapist" is defined by KRS 335.300(2).

(21) "Licensed professional clinical counselor" is defined by KRS 335.500(3).

(22) "Medical necessity" or "medically necessary" means a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

(23) "Occupational therapist" is defined by KRS 319A.010(3).

(24) "Optometrist" means an individual licensed to engage in the practice of optometry in accordance with KRS 320.210(2).

(25) "Physical therapist" is defined by KRS 327.010(2).

(24) "Physician" is defined by KRS 311.550(12).

(27) "Physician assistant" is defined by KRS 311.840(3).

(28) "Psychiatric medical resident" means an individual who:

(a) Possesses a special faculty license in accordance with KRS 311.550(29);

(b) Meets the qualification for licensure requirements established in KRS 311.571(1) or (2); and

(29) "Psychiatric registered nurse" means a registered nurse who:

(a) Has a master of science in nursing with a specialty in psychiatric or mental health nursing;

(b) Has a bachelor of science in nursing and at least one (1) year of experience in a mental health setting;

(c) Is a graduate of a three (3) year educational program and has at least two (2) years of experience in a mental health setting;

(d) Has an associate degree in nursing and at least three (3) years of experience in a mental health setting; or

(e) Has any level of education with American Nursing Association (ANA) certification as a psychiatric or mental health nurse.

(30) "Psychologist" is defined by KRS 319.010(8).

(31) "Registered nurse" is defined by KRS 314.011(5).

(32) "Speech-language pathologist" is defined by KRS 334A.020(3).

(33) "Spoke site" means a telehealth site where the recipient receiving the telehealth consultation is located.

(34) "Telehealth consultation" is defined by KRS 205.510(15),

(35) "Telehealth provider" means a Medicaid-enrolled provider, in accordance with 907 KAR 1:671 and 907 KAR 1:672, performing a telehealth consultation at a hub site.

(36) "Telehealth site" means a hub site or spoke site that has been approved as part of a telehealth network established in accordance with KRS 194A.125.

(37) "Telepresenter" means an individual operating telehealth equipment at a spoke site to enable a recipient to receive a telehealth consultation.

(38) "Transmission cost" means the cost of the telephone line and related costs incurred during the time of the transmission of a telehealth consultation.

(39) "Two (2) way interactive video" means a type of advanced telecommunications technology that permits a real time telehealth consultation to take place between a recipient and a telepresenter at the spoke site and a telehealth provider at the hub site.

Section 2. Telehealth Coverage For Telehealth Not Provided in a Community Mental Health Center. (1) The department shall reimburse for the following telehealth consultations not provided via a community mental health center in accordance with the following provisions:

(a) Wound care with a CPT code of 97601 or 97602 provided by a physician or advanced registered nurse practitioner;

(b) A service, provided by a physician, chiropractor, optometrist, or ARNP, which has an evaluation and management code of 99201 through 99215;

(c) A service, provided by a physician, chiropractor, or ARNP, with an evaluation and management code of 99241 through 99255;

(d) A psychiatric diagnosis or evaluation interview with a CPT code of 90801 through 90802 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

3. A psychologist with a license in accordance with KRS 319.010(5) and a doctorate degree in psychology directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician; or

7. An ARNP;

(e) Outpatient individual psychotherapy with a CPT code of 90804 through 90809 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician not to exceed four (4) encounters per recipient per year; or

7. An ARNP not to exceed four (4) encounters per recipient per year;

(f) Outpatient individual interactive psychotherapy with a CPT code of 90810 through 90815 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician not to exceed four (4) encounters per recipient per year; or

7. An ARNP not to exceed four (4) encounters per recipient per year;

(g) Inpatient individual psychotherapy with a CPT code of 90816 through 90822 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the telehealth encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician not to exceed four (4) encounters per recipient per year; or

7. An ARNP not to exceed four (4) encounters per recipient per year;

(h) Inpatient individual interactive psychotherapy with a CPT code of 90823 through 90829 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician not to exceed four (4) encounters per recipient per year; or

7. An ARNP not to exceed four (4) encounters per recipient per year;

(i) Other psychotherapy with a CPT code of 90845 through 90846 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician not to exceed four (4) encounters per recipient per year; or

7. An ARNP not to exceed four (4) encounters per recipient per year;

(j) Family therapy with a CPT code of 90847 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician not to exceed four (4) encounters per recipient per year; or

7. An ARNP not to exceed four (4) encounters per recipient per year;

(k) Family or group psychotherapy with a CPT code of 90849 through 90857 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician not to exceed four (4) encounters per recipient per year; or

7. An ARNP not to exceed four (4) encounters per recipient per year;

(l) Psychiatric medication management with a CPT code of 90862 if provided by:

1. A psychiatrist;

2. A physician not to exceed four (4) encounters per recipient per year; or

3. An ARNP not to exceed four (4) encounters per recipient per year;

(m) Interpretation of data to family or others with a CPT code of 90887 if provided by:

1. A psychiatrist;

2. A physician not to exceed four (4) encounters per recipient per year; or

3. An ARNP not to exceed four (4) encounters per recipient per year;

(n) A dialysis related service with a CPT code of 90918 through 90925 if provided by a physician;

(o) Initial visit with a CPT code of 99304 through 99305 to a new or established patient in a nursing home if provided by a physician or ARNP;

(p) Subsequent visit with a CPT code of 99308 through 99310 to a patient in a nursing home if provided by a physician or ARNP;

(q) Discharge of a patient from a nursing home with a CPT code of 99315 if provided by a physician or ARNP;

(r) Speech therapy evaluation with a CPT code of 92056 if provided by a speech-language pathologist;

(s) Speech therapy treatment with a CPT code of 92057 if provided by a speech-language pathologist;

(t) Occupational therapy with a CPT code of 97003 if provided by an occupational therapist;

(u) Physical therapy with a CPT code of 97001 if provided by a physical therapist;

(v) Individual medical nutrition therapy with an HCPCS code of G0270 or a CPT code of 97802 through 97804 if provided by a licensed dietitian or certified nutritionist;

(w) End stage renal disease services with an HCPCS code of G0308, G0309, G0311, G0314, G0315, G0317, or G0318 if provided by a physician or ARNP;

(x) A neurobehavioral status exam with a CPT code of 96116 if provided by:

1. A psychiatrist;

2. A licensed clinical social worker directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

4. A licensed professional clinical counselor directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

5. A licensed marriage and family therapist directly employed by a psychiatrist if the psychiatrist also interacts with the recipient during the encounter;

6. A physician not to exceed four (4) encounters per recipient per year; or

7. An ARNP not to exceed four (4) encounters per recipient per year; or

(y) Patient diabetes self-management education regarding diabetes care planning including nutrition, exercise, medication, or blood glucose testing equipment:

1. If ordered by the physician, advanced registered nurse practitioner, or physician assistant who is managing the recipient’s diabetic condition;

2. If provided by a registered nurse or dietician; and

3. With a corresponding:

a. HCPCS code of G0108 or G0109; or

b. CPT code of 97802.

(2) The department shall not reimburse for a telehealth consultation if the consultation:

(a) Is not medically necessary; or

(b) requires a face-to-face contact with a recipient in accordance with 42 C.F.R. 447.371.

(3) A telehealth consultation shall require:

(a) The use of two (2) way interactive video;

(b) A referral by a health care provider;

(d) A referral by a recipient’s lock-in provider if the recipient is locked-in pursuant to 42 C.F.R. 431.54 and 907 KAR 1:677.

Section 3. Coverage of Telehealth Provided by a Community Mental Health Center.

(1) The department shall reimburse for the following telehealth consultation provided via a community mental health center in accordance with the following provisions:

(a) A psychiatric diagnosis or evaluation interview with a CPT code of 90801 through 90802 if provided by:

1. A psychiatrist;

2. A physician;

3. A psychologist with a license in accordance with KRS 319.010(5);

4. A licensed marriage and family therapist;

5. A licensed professional clinical counselor;

6. A psychiatric medical resident;

7. A psychiatric registered nurse;

8. A licensed clinical social worker; or

9. An advanced registered nurse practitioner;

(b) Outpatient individual psychotherapy with a CPT code of 90804 through 90809 if provided by:

1. A psychiatrist;

2. A physician;

3. A psychologist with a license in accordance with KRS 319.010(5);

4. A licensed marriage and family therapist;

5. A licensed professional clinical counselor;

6. A psychiatric medical resident;

7. A psychiatric registered nurse;

8. A licensed clinical social worker; or

9. An advanced registered nurse practitioner;

1. A psychiatrist;

2. A physician;

3. A psychologist with a license in accordance with KRS 319.010(5);

4. A licensed marriage and family therapist;

5. A licensed professional clinical counselor;

6. A psychiatric medical resident;

7. A psychiatric registered nurse;

8. A licensed clinical social worker; or

9. An advanced registered nurse practitioner;

(d) Inpatient individual psychotherapy with a CPT code of 90816 through 90822 if provided by:

1. A psychiatrist;

2. A physician;

3. A psychologist with a license in accordance with KRS 319.010(5);

4. A licensed marriage and family therapist;

5. A licensed professional clinical counselor;

6. A psychiatric medical resident;

7. A psychiatric registered nurse;

8. A licensed clinical social worker; or

9. An advanced registered nurse practitioner;

(e) Inpatient individual interactive psychotherapy with a CPT code of 90823 through 90829 if provided by:

1. A psychiatrist;

2. A physician;

3. A psychologist with a license in accordance with KRS 319.010(5);

4. A licensed marriage and family therapist;

5. A licensed professional clinical counselor;

6. A psychiatric medical resident;

7. A psychiatric registered nurse;

8. A licensed clinical social worker; or

9. An advanced registered nurse practitioner;

(f) Other psychotherapy with a CPT code of 90845 through 90846 if provided by:

1. A psychiatrist;

2. A physician;

3. A psychologist with a license in accordance with KRS 319.010(5);

4. A licensed marriage and family therapist;

5. A licensed professional clinical counselor;

6. A psychiatric medical resident;

7. A psychiatric registered nurse;

8. A licensed clinical social worker; or

9. An advanced registered nurse practitioner;

(g) Family therapy with a CPT code of 90847 if provided by:

1. A psychiatrist;

2. A physician;

3. A psychologist with a license in accordance with KRS 319.010(5);

4. A licensed marriage and family therapist;

5. A licensed professional clinical counselor;

6. A psychiatric medical resident;

7. A psychiatric registered nurse;

8. A licensed clinical social worker; or

9. An advanced registered nurse practitioner;

(h) Family or group psychotherapy with a CPT code of 90849 through 90857 if provided by:

1. A psychiatrist;

2. A physician;

3. A psychologist with a license in accordance with KRS 319.010(5);

4. A licensed marriage and family therapist;

5. A licensed professional clinical counselor;

6. A psychiatric medical resident;

7. A psychiatric registered nurse;

8. A licensed clinical social worker; or

9. An advanced registered nurse practitioner;

(i) Psychiatric medication management with a CPT code of 90862 if provided by:

1. A psychiatrist;

2. A physician;

3. A psychiatric medical resident; or

4. An ARNP;

(j) Interpretation of data to family or others with a CPT code of 90887 if provided by:

1. A psychiatrist;

2. A physician; or

3. An ARNP; or

(k) A neurobehavioral status exam with a CPT code of 96116 if provided by:

1. A psychiatrist; or

2. A psychologist with a license in accordance with KRS 319.010(5).

(2) The department shall not reimburse for a telehealth consultation if the consultation:

(a) Is not medically necessary; or

(b) Requires a face-to-face contact with a recipient in accordance with 42 C.F.R. 447.371.

(3) A telehealth consultation shall require:

(a) The use of two (2) way interactive video;

(b) A referral by a health care provider;

(d) A referral by a recipient’s lock-in provider if the recipient is locked-in pursuant to 42 C.F.R. 431.54 and 907 KAR 1:677.

Section 4. Reimbursement. (1) The department shall reimburse a telehealth provider for a telehealth consultation:

(a) Except for a telehealth consultation provided by an ARNP or CMHC, an amount equal to the amount paid for a comparable in-person service in accordance with 907 KAR 3:010;

(b) If a CMHC, in accordance with 907 KAR 1:045; or

(c) If provided by an ARNP, an amount equal to the amount paid for a comparable in person service in accordance with 907 KAR 1:104.

(2) A telehealth provider shall bill for a telehealth consultation using the appropriate evaluation and management CPT or HCPCS codeas specified in Section 2 or 3 of this administrative regulation along with the corresponding two (2) letter "GT" modifier.

(3) The department shall not require the presence of a health care provider requesting a telehealth consultation at the time of the telehealth consultation unless it is requested by a telehealth provider at the hub site.

(4) The department shall not reimburse for transmission costs.

Section 5. Confidentiality and Data Integrity. (1) A telehealth consultation shall be performed on a secure telecommunications line or utilize a method of encryption adequate to protect the confidentiality and integrity of the telehealth consultation information.

(2) Both a hub site and a spoke site shall use authentication and identification to ensure the confidentiality of a telehealth consultation.

(3) A provider of a telehealth consultation shall implement confidentiality protocols that include:

(a) Identifying personnel who have access to a telehealth transmission;

(b) Usage of unique passwords or identifiers for each employee or person with access to a telehealth transmission; and

(4) A provider’s protocols and guidelines shall be available for inspection by the department upon request.

Section 6. Informed Consent. (1) Before providing a telehealth consultation to a recipient, a health care provider shall document written informed consent from the recipient and shall ensure that the following written information is provided to the recipient in a format and manner that the recipient is able to understand:

(a) The recipient shall have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which the recipient is entitled;

(b) The recipient shall be informed of alternatives to the telehealth consultation that are available to the recipient;

(c) The recipient shall have access to medical information resulting from the telehealth consultation as provided by law;

(d) The dissemination, storage, or retention of an identifiable recipient image or other information from the telehealth consultation shall comply with 42 U.S.C. 1301 et seq., 45 C.F.R. Parts 160, 162, 164, KRS 205.566, 216.2927, and any other federal law or regulation or state law establishing individual health care data confidentiality provisions;

(e) The recipient shall have the right to be informed of the parties who will be present at the spoke site and the hub site during the telehealth consultation and shall have the right to exclude anyone from either site; and

(f) The recipient shall have the right to object to the video taping of a telehealth consultation.

(2) A copy of the signed informed consent shall be retained in the recipient's medical record and provided to the recipient or the recipient's legally-authorized representative upon request.

(3) The requirement to obtain informed consent before providing a telehealth consultation shall not apply to an emergency situation if the recipient is unable to provide informed consent and the recipient's legally-authorized representative is unavailable.

Section 7. Medical Records. (1) A request for a telehealth consultation from a health care provider and the medical necessity for the telehealth consultation shall be documented in the recipient's medical record.

(2) A health care provider shall keep a complete medical record of a telehealth consultation provided to a recipient and follow applicable state and federal statutes and regulations for medical recordkeeping and confidentiality in accordance with KRS 194A.060, 422.317, 434.840 - 434.860, 42 C.F.R. 431.300 to 431.307, and 45 C.F.R. 164.530(j).

(3) A medical record of a telehealth consultation shall be maintained in compliance with 907 KAR 1:672 and 45 C.F.R. 164.530(j).

(4) Documentation of a telehealth consultation by the referring health care provider shall be included in the recipient's medical record and shall include:

(a) The diagnosis and treatment plan resulting from the telehealth consultation and a progress note by the referring health care provider if present at the spoke site during the telehealth consultation;

(b) The location of the hub site and spoke site;

(d) Documentation supporting the medical necessity of the telehealth consultation.

(5)(a) A telehealth provider's diagnosis and recommendations resulting from a telehealth consultation shall be documented in the recipient's medical record at the office of the health care provider who requested the telehealth consultation.

(b) A telehealth provider shall send a written report regarding a telehealth consultation within thirty (30) days of the consultation to the referring health care provider.

Section 8. Federal Financial Participation. A provision established in this administrative regulation shall be effective contingent upon the department’s receipt of federal financial participation for the respective provision.

Section 9. Appeal Rights. (1) An appeal of a department determination regarding a Medicaid beneficiary shall be in accordance with 907 KAR 1:563.

(2) An appeal of a department determination regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

(3) A provider may appeal a department-written determination as to the application of this administrative regulation in accordance with 907 KAR 1:671. (28 Ky.R. 150; Am. 1430; eff. 12-19-2001; 30 Ky.R. 1861; 2055; eff. 3-18-2004; 32 Ky.R. 1934; 2279; eff. 7-7-2006; 35 Ky.R. 1923; 2456; 2757; eff. 7-6-2009.)