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WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.
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AMA/ADA End User License Agreement
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT® ")

You, your employees and agents are authorized to use CPT only as contained in materials on the Texas Medicaid & Healthcare Partnership (TMHP) website solely for your own personal use in directly participating in healthcare programs administered by THHS. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, 515 N. State Street, Chicago, Illinois, 60610. Applications are available at the American Medical Association website, www.ama-assn.org/go/cpt.

U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer databases and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer databases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the American Medical Association (AMA) is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with THHS, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the for egoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "accept".

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1. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights included in the materials.

2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.

3. U.S. GOVERNMENT RIGHTS. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government Use. This product includes CDT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal Procurements.

4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does no t directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with TMHP or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of the Agreement. The ADA is a third party beneficiary to this Agreement.

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Telemedicine and Telehealth Benefit Information to Be Updated September 1, 2022

Last updated on 9/2/2022

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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 September 1, 2022, telemedicine and telehealth benefit information will be updated for Texas Medicaid.

Note: Telehealth includes teledentistry services.

Overview of Benefit Changes

Major changes to the benefit information include the following:

Described and defined audio-only services
Clarified that coverage of behavioral health (BH) audio-only services is not optional for health plans
Added language regarding when audio-only services may be authorized for use
Added language regarding the use of the 93 and FQ modifiers
Reorganization of information about specific telemedicine and telehealth services within the Texas Medicaid Provider Procedures Manual handbooks

Definitions of Terminology

Telemedicine and telehealth services have the meaning assigned by Texas Occupations Code §111.001. The following are definitions of terms used in telemedicine and telehealth services:

Telecommunications - the exchange of information by electronic and electrical means
Platform - the technology, system, software, application, modality, or other method through which a health professional remotely interfaces with a client when providing a health care service or procedure as a telemedicine medical service or telehealth service
Audiovisual technology- synchronous audiovisual technology or store-and-forward technology in conjunction with synchronous audio-only technology
Synchronous audiovisual technology - an interactive, two-way audio and video telecommunications platform that meets the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA)
Synchronous audio-only technology, also called synchronous telephone (audio-only) technology - an interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of HIPAA
Store-and-forward technology - a telecommunications platform that stores and transmits, or grants access to, a client’s clinical information for review by a health professional at a different physical location from the client
In person (or in-person) - within the physical presence of another person

Services Provided through Synchronous Audio-Only Technology

Synchronous telephone (audio-only) technology between the provider and the client in another location may be used to provide telemedicine and telehealth services within fee-for-service (FFS) Medicaid. Providers must ensure both the covered service and the delivery method are authorized by the Texas Health and Human Services Commission (HHSC).

Telemedicine and telehealth services provided through synchronous telephone (audio-only) technology must be billed with the appropriate modifier (93 or FQ), unless the procedure code indicates telephone (audio-only) delivery in the code description.

Behavioral Health Services

Behavioral health services provided through synchronous audio-only technology require the provider to obtain informed consent from the client, client’s parent, or the client’s legally authorized representative (LAR) before rendering a behavioral health service through a synchronous telephone (audio-only) technology platform, except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.

Telemedicine and telehealth behavioral health services provided through synchronous telephone (audio-only) technology must be billed with a modifier. Procedure codes that indicate telephone (audio-only) delivery in the description do not need to be billed with a modifier.

Additional Guidelines for Telemedicine and Telehealth Services

The following delivery methods may be used to provide telemedicine and telehealth services within FFS Medicaid:

Synchronous audiovisual technology between the distant-site provider and the client in another location
Synchronous telephone (audio-only) technology between the distant-site provider and the client in another location
Store-and-forward technology, in conjunction with synchronous telephone (audio-only) technology between the distant-site provider and the client in another location.

Not all Medicaid-covered services are authorized by HHSC for telemedicine or telehealth delivery in FFS. Providers must ensure that HHSC both allows the Medicaid-covered service to be delivered through telemedicine or telehealth and authorizes the delivery method.

For example, if a service is authorized for telemedicine delivery only when using synchronous audiovisual technology, that service may not be delivered using store-and-forward technology, store-and-forward technology in conjunction with synchronous telephone (audio-only) technology, synchronous telephone (audio-only) technology, or asynchronous audio-only technology.

Reminder: Texas Medicaid managed care organiziations (MCOs) must consider reimbursement for all medically necessary Medicaid-covered services that are provided using telemedicine or telehealth. Providers should refer to individual MCO policies for additional coverage information.

Conditions for Reimbursement

Telemedicine and telehealth services that may be reimbursed are those that meet the following conditions when delivered using any of the methods noted above:

Are designated for reimbursement by HHSC
Meet criteria, including clinical effectiveness, cost-effectiveness, and other criteria, as determined by HHSC
Are provided by a Texas Medicaid enrolled provider
Are both in compliance with Chapter 111 of the Texas Occupations Code and within standards established by the respective licensing or certifying board of the professional providing the service
May not be denied solely because an in-person healthcare service between a provider and client did not occur
May not be limited by requiring the provider to use a particular technology platform to receive reimbursement for the service
Other conditions for reimbursement applicable to services provided may vary by service type. Providers may refer to the appropriate Texas Medicaid Provider Procedures Manual handbook for additional information.

Beginning September 1, 2022, procedure codes that are benefits for providers delivering services through telemedicine or telehealth will be outlined in the respective Texas Medicaid Provider Procedures Manual handbooks.

Note: During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of telemedicine or telehealth services, including the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described in this article. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

Additional Guidelines for Telemedicine Services

All physicians must comply with 22 Texas Administrative Code §174.5 when issuing prescriptions through telemedicine.

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