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Overview of Telemonitoring Benefit Changes for the CSHCN Services Program

Last updated on 2/26/2019

Effective for dates of service on or after January 1, 2019, telemonitoring benefits will change for the Children with Special Health Care Needs (CSHCN) Services Program.

Overview of Benefit Changes

Major changes to this medical benefit policy include the following:

  • New procedure code for home health agency and hospital providers
  • New modifier requirements
  • Removal of requirement to submit claims to Medicare for Medicare-Medicaid dual eligible clients

New Procedure Code and Modifier Requirements

Procedure codes 99090 and 99090 with the GQ modifier are discontinued. Additionally, procedure codes 99453 and 99454 will no longer be benefits and will be replaced with procedure code S9110 and the following modifiers:

Procedure Code

Modifier

Description of Service

S9110

U1

Initial setup and installation of equipment

U2

Monthly home monitoring (1 to 5 days per rolling month)

U3

Monthly home monitoring (6 to 10 days per rolling month)

U4

Monthly home monitoring (11 to 15 days per rolling month)

U7

Monthly home monitoring (16 to 20 days per rolling month)

U8

Monthly home monitoring (21 to 25 days per rolling month)

U9

Monthly home monitoring (26 to 30 days per rolling month)

Procedure code S9110 requires prior authorization and will be a benefit as follows:

  • To home health agency providers for services rendered in the home setting
  • To hospital providers for services rendered in the outpatient hospital setting

Hospital providers must submit revenue code 780 with procedure code S9110.

Initial Setup and Installation

Prior authorization requests for the initial setup and installation (procedure code S9110 with modifier U1) will be approved once per episode of care, even if monitoring parameters are added after initial setup and installation.

The prior authorization request for setup and installation must include modifier U1 with procedure code S9110.

A claim for a subsequent set up and installation will not be reimbursed unless there is a documented new episode of care.

Monthly Home Monitoring

Claims for monthly home monitoring must be submitted with the appropriate modifier to indicate the number of days that transmission of data was received and reviewed for the client within a rolling month.

The prior authorization request for monthly home monitoring does not require a modifier, and should only list procedure code S9110.

A prior authorization request for monthly home telemonitoring may be approved once per month for the length of the prior authorization period.

Previously Approved Prior Authorization Requests

Providers who have already received prior authorization for procedure code 99090, 99090 with modifier GQ, 99453, or 99454 are not required to update prior authorization requests.

TMHP will automatically update affected prior authorization requests with procedure code S9110 and the appropriate modifier. New approval letters will be issued to providers whose prior authorizations were updated.

Claims Filing for Medicare Dual Eligible Clients

Procedure code S9110 is not a benefit of Medicare. Claims for procedure code S9110, with any modifier, are not required to be submitted to Medicare before submitting a claim or prior authorization request to TMHP.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.