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Telehealth Services Benefit Policy Updated Effective August 1, 2019

Last updated on 6/14/2019

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after August 1, 2019, telehealth benefit policy language will be updated for Texas Medicaid. The policy updates are a component of the Health and Human Services Commission (HHSC) implementation of Senate Bill (S.B) 922, 85th Legislature, 2017. S.B. 922 will require HHSC to reimburse occupational therapists (OT) and speech-language pathologists (SLPs) for telehealth services delivered to children in school-based settings.

Added Distant Site Providers

Post-doctoral psychology fellows and pre-doctoral psychology interns under a psychologist supervision may deliver telehealth services.

School Health and Related Services (SHARS), occupational therapist, home health, and Comprehensive Care Program (CCP) providers for OT and speech therapy (ST) may be reimbursed for services rendered in the home setting.

SHARS and home health providers may be reimbursed for services rendered in other locations setting.

School-Based Telehealth Services

OT and ST providers may be reimbursed for telehealth services delivered to children in school-based settings with the following criteria:

  • Reimbursement for OT and ST providers is only available when the patient site is a school-based setting.
  • Children receiving telehealth services rendered by OT and ST providers must be eligible for these services through Texas Health Steps CCP.
  • All medical necessity criteria and prior authorization requirements for in-person OT and ST services apply when services are delivered to children in school-based settings.
  • Services provided to a patient on public school or open-enrollment charter school premises are only permitted when delivered before or after school hours.
  • All other prior authorization, reimbursement, and billing guidelines that are applicable to in-person services will also apply when OT and ST services are delivered as telehealth services.

Licensed clinical social workers (LCSW), licensed professional counselors (LPC), licensed marriage and family therapists (LMFT), and psychologist providers may be reimbursed for telehealth services in school-based settings.

Children receiving telehealth services rendered by LCSW, LPC, LMFT, and psychologist providers must be eligible for these services through Texas Health Steps CCP or through SHARS.

SHARS Telehealth Services

Schools that participate in the SHARS may be reimbursed for telehealth OT and ST services delivered to children in school-based settings with the following criteria:

  • Children who are eligible for OT and ST services through SHARS may receive additional therapy through Texas Health Steps CCP if medical necessity criteria is met.
  • OT and ST services provided by school districts through SHARS can be delivered during school hours.
  • Providers may refer to the Texas Medicaid Provider Procedures Manual, Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook, section 5, “Children’s Therapy Services Clients birth through 20 years of age,” for more information on services, benefits, and limitations for OT and SLP services.

Authorization Requirements

The following initial evaluation and re-evaluation procedure codes do not require prior authorization for telehealth services:

Procedure Codes

92521

92522

92523

92524

97165

97166

97167

The following evaluation and re-evaluation procedure codes require prior authorization for telehealth services:

Procedure Codes

92507

92508

97150

97168

97530

S9152

Prior authorization is not required for procedure codes 92507, 92508, or 97150 when services are provided through SHARS.

Reimbursement

Telehealth services should be billed using the 95 modifer. The following OT and ST procedure codes may be reimbursed when rendered as telehealth services to children eligible through Texas Health Steps CCP:

Procedure Codes

92507

92508

92521

92522

92523

92524

97150

97165

97166

97167

97168

97530

S9152

 

The following OT and ST procedure codes may be reimbursed when rendered as telehealth services to children eligible for services through SHARS:

Procedure Codes

92507

92508

92521

92522

92523

92524

97150

97165

97166

97167

97530

Procedure codes 92507, 92508, 92521, 92522, 92523, 92524, 97150, and 97530 should also be billed with the following modifier(s):

Modifier

Description

GO

OT services

GN

ST services

AT

Acute OT or ST services

Modifiers GO and GN are required on all claims except when billing evaluation and re-evaluation procedure codes. The AT modifier must be included on claims for acute therapy services.

Providers may refer to the Texas Medicaid Provider Procedures Manual, Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook, section 6.3.4, “PT, OT, and ST Evaluation and Re-evaluation Procedure Codes,” for more information.

For more information, call the TMHP Contact Center at 800-925-9126.