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Telehealth Policy Update for Medi-Cal and Family PACT Programs

August 5, 2019

Effective for dates of service on or after July 1, 2019, telehealth policy is updated pursuant to Assembly Bill 415 (Logue, Chapter 547, Statutes of 2011), known as the Telehealth Advancement Act of 2011. Benefits or services covered under the Medi-Cal and Family PACT programs, identified by CPT or HCPCS codes and subject to all existing Medi-Cal and Family PACT coverage and reimbursement policies, including any Treatment Authorization Request (TAR) requirements, may be provided via a telehealth modality, if all of the following are satisfied:

  • The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
  • The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the service or benefit covered under the Medi-Cal and Family PACT programs, as well as any extended guidelines as described in the Medi-Cal and Family PACT provider manuals; and
  • The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Health care providers are required to document Place of Service code “02” on the claim, which indicates that services were provided or received through a telecommunications system.

Modifier GT is no longer required. Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

  • For services or benefits provided via synchronous, interactive audio and telecommunications systems, the health care provider bills with modifier 95.
  • For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.

In addition, CPT code 99451 (interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician) is reimbursable for e-consults.

Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services – Memorandum of Agreement (IHS-MOA) 638, Clinics may also bill their respective services via a telehealth modality.

Modifier 95 is required to bill for Local Educational Agency (LEA) Medi-Cal Billing Option Program services provided via a telehealth modality.

Full details regarding the updated telehealth guidelines, including the specific requirements for FQHCs, RHCs and IHS-MOA clinics, will be published in the Medi-Cal provider manuals and the Family PACT Policies, Procedures and Billing Instructions in a future Medi-Cal Update and Family PACT Update.