Telemedicine and eConsult Billing Manual

• General Billing Information
  • COVID-19 Emergency Policy Flexibilities Made Permanent
  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
• Telemedicine Overview
  • Telehealth Home Health Monitoring
  • eHealth Entity Provider Specialty Type
  • Requirements for Telemedicine Services
  • Covered Services
  • Non-Covered Services
  • Hospital Services Rendered via Telemedicine
• Health First Colorado Reimbursement for Telemedicine
  • Telemedicine for Primary Care Providers
  • Telemedicine for Specialty Care Providers
  • Telemedicine for Federally Qualified Health Centers, Rural Health Clinics and Indian Health Services
  • Physical Therapy, Occupational Therapy, Home Health, Hospice and Pediatric Behavioral Therapy Providers
  • Allowable Locations for Telemedicine
• Telemedicine Confidentiality Requirements
• Waiving the Face-to-Face Requirement & Required Disclosure Statements
• Telemedicine Billing Procedure Codes
• Billing Providers
• Originating Site Billing
• Distant Providers
• Billing HCPCS Q3014
• Telemedicine Place of Service Codes
• Rendering Providers
  • Telemedicine Modifier GT
• eConsults Overview
• CMS 1500 Paper Claim Reference Table
  • Telemedicine Originator Claim Example
  • Telemedicine Distant Claim Example
• Timely Filing
• Telemedicine Revision Log

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General Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page for general billing information.

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COVID-19 Emergency Policy Flexibilities Made Permanent

Refer to the End of the Public Health Emergency web page under the Emergency Policy Flexibilities Made Permanent section.
 

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Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

8.280.4.E Other EPSDT Benefits

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
2. For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
3. The service provides a safe environment or situation for the child.
4. The service is not for the convenience of the caregiver.
5. The service is medically necessary.
6. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
7. The service is the least costly.

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Telemedicine Overview

Telemedicine is not a unique service, but a means of providing services approved by Health First Colorado through live interactive audio and video telecommunications equipment. 

Telemedicine services may be provided under two arrangements:

1. When a member receives services via a live audio/visual connection from a single provider. When a member and a provider are physically in the same location and additional services are provided by a second (distant) provider via a live audio/visual connection.

In this arrangement the provider who is present with the member is called the originating provider, and the provider located at a different site, acting as a consultant, is called the distant provider.

A telemedicine visit is conducted between a member and provider in which, the  member must be present during telemedicine visits.
Providers should refer to the Code of Colorado Regulations Program Rules (10 CCR 2505-10, Section 8.095), for specific information when providing telemedicine services.

When a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC) provides care through telemedicine, the claim must include the modifier GT on line(s) identifying the service(s). The claims must follow the other requirements of an FQHC or RHC claim as identified in the FQHC and RHC Billing Manual.
 

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Telehealth Home Health Monitoring

Telehealth monitoring is available for members who are eligible through the Home Health benefit and should not be billed as telemedicine. Providers rendering telehealth monitoring should refer to the Home Health Billing Manual located on the Billing Manuals web page under the CMS 1500 drop-down menu. 

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eHealth Entity Provider Specialty Type

As of October 30th, 2022, there is a provider specialty type for Clinic and Non-Physician Practitioner groups that meet the following definition:

An eHealth entity is defined as a group practice that delivers services exclusively through telemedicine and is enrolled in a provider type that has an eHealth specialty.

Refer to the Code of Colorado Regulations (1- CCR 2505-10, Section 8.095) for more information. Providers who meet this definition must update their enrollment to this provider specialty type. Visit the Provider Enrollment web page for guidance on how to enroll. Services are restricted to those currently allowed for telemedicine. This information is located under Covered Services.

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Covered Services

See Telemedicine  - General Billing Information for a list of billing codes which may be used with Place of Service (POS) 02 or 10.

Services may be rendered via telemedicine when the service is:

• A covered Health First Colorado benefit,
• Within the scope and training of an enrolled provider's license, and
• Appropriate to be rendered via telemedicine.

All services provided through telemedicine shall meet the same standard of care as in-person care.

The availability of services through telemedicine in no way alters the scope of practice of any health care provider, nor does it authorize the delivery of health care services in a setting or manner not otherwise authorized by law. [C. R. S. 2018, 25.5-5-414 (7)(a) & (b)

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Non-Covered Services

• Services not otherwise covered by Health First Colorado are not covered when delivered via telemedicine
• Telemedicine does not include provider-to-provider consultations provided by telephone (interactive audio), email or facsimile machines.
• Services appropriately billed to managed care should continue to be billed to managed care. All managed care requirements must be met for services billed to managed care. Managed care may or may not reimburse telemedicine costs.
• Health First Colorado does not pay for provider education via telemedicine.
• The use of telecommunications equipment for delivery of services does not change prior authorization requirements established for the services being provided.

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Hospital Services Rendered via Telemedicine

Only Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Pathology (SLP) when rendered via telemedicine are allowed to be billed on an outpatient hospital claim. Services which may be rendered via telemedicine are outlined below in the Telemedicine Billing Procedure Codes.

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Health First Colorado Reimbursement for Telemedicine

Telemedicine for Primary Care Providers

A primary care provider can be reimbursed as the "originating provider" for any eligible Telemedicine Services where the member is present with the provider at the "originating site." Please see the 'Originating Site Billing' section for further information on reimbursement requirements for providers at an originating site with a member.

In order for a primary care provider to be reimbursed for Telemedicine Services as the "distant provider" the primary care provider must be able to facilitate an in-person visit in the state of Colorado if necessary for treatment of the member's condition. Please see the 'Distant Provider Billing' section for further information.

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Telemedicine for Specialty Care Providers

A medical specialist provider can be reimbursed as the "originating provider" for any Telemedicine Services where the member is present with the provider at the "originating site." Please see the 'Originating Site Billing' section for further information on reimbursement requirements for providers at an originating site with a member.

A medical specialist provider can be reimbursed as the "distant provider." Please see the 'Distant Provider Billing' section for further information.

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Telemedicine for Federally Qualified Health Centers, Rural Health Clinics, and Indian Health Services

Health First Colorado allows telemedicine visits to qualify as billable encounters for Federally Qualified Health Centers (FQHCs), Rural Health Clinic (RHCs), and Indian Health Services (IHS). Services allowed under telemedicine may be provided via telephone, live chat, or interactive audiovisual modality for these provider types.

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Physical Therapy, Occupational Therapy, Home Health, Hospice and Pediatric Behavioral Therapy Providers

Physical therapists, occupational therapists, hospice, home health providers and pediatric behavioral therapy providers are eligible to deliver telemedicine services.

1. Home Health Agency services and therapies, Hospice, and Pediatric Behavioral Treatment may be provided via any telemedicine modality.
2. Outpatient Physical, Occupational, and Speech Therapy services must have an interactive audio/visual connection with the member to be provided via telemedicine.

Telemedicine is covered for behavioral therapy providers under the capitated behavioral health benefit administered by the Regional Accountable Entities (RAEs). Behavioral health providers should contact their RAE for guidance. Visit the Accountable Care Collaborative Phase II web page for more information.

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Allowable Locations for Telemedicine

If no originating provider is present during a Telemedicine Services appointment, then the location of the originating site is at the member's discretion and can include the member's home. However, members can be required to choose a location suitable to delivery of telemedicine services that may include adequate lighting and environmental noise levels suitable for easy conversation with a provider.

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Telemedicine Confidentiality Requirements

All Health First Colorado providers using telemedicine to deliver Health First Colorado services must employ existing quality-of-care protocols and member confidentiality guidelines when providing telemedicine services. Health benefits provided through telemedicine must meet the same standard of care as in-person care. Record-keeping should comply with Health First Colorado requirements in 10 CCR 2505-10, Section 8.130.2.

Transmissions must be performed on dedicated secure lines or must utilize an acceptable method of encryption adequate to protect the confidentiality and integrity of the transmission. Transmissions must employ acceptable authentication and identification procedures by both the sender and the receiver. Providers of telemedicine services must implement confidentiality procedures that include, but are not limited to:

• Specifying the individuals who have access to electronic records
• Using unique passwords or identifiers for each employee or other person with access to the member records
• Ensuring a system to routinely track and permanently record such electronic medical information
• Advising members of their right to privacy and that their selection of a location to receive telemedicine services in private or public environments is at the member's discretion

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Waiving the Face-to-Face Requirement & Required Disclosure Statements

The Health First Colorado requirement for an initial face-to-face contact between provider and member may be waived when treating the member through telemedicine. In-person contact between a health care provider and a member is not required for services delivered through telemedicine that are otherwise eligible for reimbursement.

Prior to treating the member through telemedicine for the first time, the provider must furnish each member with all of the following written statements, which must be signed (electronic signatures will be accepted) by the member or the member's legal representative:

• The member retains the option to refuse the delivery of health care services via telemedicine at any time without affecting the member's right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the member would otherwise be entitled.
• All applicable confidentiality protections shall apply to the services.
• The members shall have access to all medical information resulting from the telemedicine services as provided by applicable law for member access to his or her medical records. [C. R. S. 2018, 25.5-5-320 (4)].

These requirements do not apply in an emergency. [C. R. S. 2018, 25.5-5-320 (5)].

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Telemedicine Billing Procedure Codes

Specific coverage and billing information may exist for the benefit being provided via Telemedicine. Refer to the Billing Manuals web page for benefit-specific details.

The following list of CPT/HCPCS codes codes are allowable via telemedicine. When delivered via telemedicine Place of Service code 02 or 10 must be used:

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Billing Providers

Telemedicine services will only be reimbursed for providers who are enrolled in Health First Colorado at the time of service.

The availability of services through telemedicine in no way alters the scope of practice of any health care provider, nor does it authorize the delivery of health care services in a setting or manner not otherwise authorized by law. [C. R. S. 2018, 25.5-5-414 (7)(a) & (b)].

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Originating Site Billing

The originating site (originating provider) is where the member is located. For an allowable provider type to bill for the originating site facility fee, the member and provider must be physically present in the same location.

The originating provider may bill for other Health First Colorado-covered services that were provided during the same visit as the Telemedicine visit.

In some cases, the originating provider site will not be providing clinical services, but only providing a site and telecommunications equipment. In this situation, the telemedicine originating site facility fee is billed using procedure code Q3014.

Originating providers bill as follows:

• If the originating provider is making a room and telecommunications equipment available but is not providing clinical services, the originating provider bills Q3014 (the procedure code for the telemedicine originating site facility fee).
• If the originating provider also provides clinical services to the member, the provider bills the rendering provider's appropriate procedure code and bills Q3014.
• The originating provider may also bill, as appropriate, on the UB-04 paper claim form or as an 837I transaction for any clinical services provided on-site on the same day that a telemedicine originating site claim is made. The originating provider must submit two separate claims for the member's two separate services.

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Distant Providers

All distant providers should bill the appropriate procedure code and Place of Service 02 or 10 and FQ or FR modifiers if appropriate on the CMS 1500 paper claim form or as an 837P transaction.

When the patient is located in a hospital, please use the appropriate place of service code for where the patient is located.

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Billing HCPCS Q3014

The following provider types may bill procedure code Q3014 (telemedicine originating site facility fee):

Provider types not listed above may facilitate Telemedicine Services with a distant provider but may not bill procedure code Q3014. Examples include Nursing Facilities, Intermediate Care Facilities, Assisted Living Facilities, etc.

If practitioners at both the originating site and the distant site provide the same service to the member, both providers submit claims using the same procedure code with modifier 77 (Repeat procedure by another physician).

The originating site may not bill for assisting the distant site provider with an examination.

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Telemedicine Place of Service Codes

All rendering providers must bill the appropriate procedure code using Place of Service code 02 or 10 and the appropriate modifiers FQ, FR, 93 or 95 on the CMS 1500 paper claim form or as an 837P transaction.

When the patient is located in a hospital, please use the appropriate place of service code for where the patient is located.

Place of Services codes 02 and 10 can be used during telehealth encounters:

• POS 02: Telehealth provided other than in the patient’s home. 
• POS 10: Telehealth provided in patient’s home.  

Additionally, modifiers FQ, FR, 93 and 95 can be added to POS 2 and 10:

• FQ: The service was furnished using audio-only communication technology.

• FR: The supervising practitioner was present through two (2)

  ---

  -way, audio/video communication technology.

• 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
• 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System 

The following provider types may bill using modifier GT:

Procedure codes listed below under Telemedicine Modifier GT" will receive an additional $5.00 to the fee listed on the most recent Health First Colorado Fee Schedule when billed using modifier GT.

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Rendering Providers

If a rendering provider's number is required on the claim for a face-to-face visit, it is required on the claim for a telemedicine visit.

Clinics and the other provider types are required to enter the rendering provider's Health First Colorado provider number in field 19D.

When an originating site bills Q3014 (telemedicine originating site facility fee), there is generally no rendering provider actually involved in the service at the originating site.

However, a rendering provider number is still required and must be affiliated with the billing provider. The facility may enter either the member's usual provider's number, or another provider number affiliated with that site as the rendering provider.

When the member sees a rendering provider at the originating site and also uses the site as the telemedicine originating site, the facility bills the rendered service procedure code and Q3014 for the use of the telemedicine facility. The same rendering provider number is entered in field 19D.

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Telemedicine Modifier GT

When used by an FQHC or RHC, the modifier GT identifies the services as being delivered through telemedicine modality. There is no enhanced payment to FQHCs and RHCs when using the modifier GT.

The following procedure codes, when billed with modifier GT by appropriate providers, pay the telemedicine transmission fee (an additional $5.00 to the fee listed in the most recent Health First Colorado Fee Schedule). Any other procedure codes billed with modifier GT will not pay the telemedicine transmission fee. When providing Family Planning via Telemedicine, appropriate providers may use the combination modifier codes of FP/GT (in this order).

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eConsults Overview

Effective February 1, 2024, eConsults that meet the criteria below are a covered benefit.

An eConsult is defined as an asynchronous dialogue initiated by a Treating Practitioner seeking a Consulting Practitioner’s expert opinion without a face-to-face member encounter with the Consulting Practitioner.

Treating Practitioner is defined as a member’s treating physician or other qualified health care practitioner who is a primary care provider contracted with a Regional Accountable Entity to participate in the Accountable Care Collaborative as a Network Provider.

Consulting Practitioner is defined as a provider who has education, training or qualifications in a specialty field other than primary care.

Providers can utilize the Department's eConsult platform, Colorado Medicaid eConsult, or a third-party eConsult platform that meets the Department’s criteria. 

Approved Third-Party eConsult Platform Criteria

1. Platform must be capable of maintaining documentation that the eConsult is directly relevant to the individual patient’s diagnosis and treatment, and the consulting practitioner has specialized expertise in the particular health concerns of the patient.
2. Platform must be capable of identifying the Colorado Medicaid enrollment status of providers using the platform. All providers must be licensed in the state of Colorado.
3. Platform meets all state and federal privacy laws regarding the exchange of patient information. 
4. Platform must be capable of providing sufficient documentation for the treating and consulting provider to demonstrate that the consultation was provided for the direct benefit of the member.
5. Platform must provide the treating and consulting practitioner with the information necessary to file a claim including date of service; name of recipient; Medicaid identification number; name of provider agency or person providing the service; nature, extent or units of service and the place of service.

Treating practitioners can bill this service using Procedure Code 99452. 

• The date of service for 99452 should be the date the eConsult was completed.
• Treating practitioners use 99452 to report an eConsult outside of an evaluation and management service. An eConsult completed on the same date of service as an office visit is considered part of the evaluation and management service and will not be reimbursed separately. 
• Services must meet the procedural definition and components, including time requirements, of the CPT code as defined by the AMA in addition to requirements listed here.

Consulting practitioners can bill this service using Procedure Code 99451. 

Treating Practitioner Reimbursement: 

• All practitioners rendering services should submit claims for completed eConsults for fee-for-service reimbursement. 

Consulting Practitioner Reimbursement:

• Consulting practitioners who use the Department's eConsult platform will be paid by Safety Net Connect's subcontractor, ConferMED. 
• Consulting practitioners who use an approved eConsult platform should submit claims for completed eConsults to the Colorado interChange for fee-for-service reimbursement.

Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs)

eConsult dialogues between Treating Practitioners and Consulting Practitioners do not meet the definition of an FQHC or RHC visit as defined in CCR 8.700. Costs associated with performing eConsults through an FQHC/RHC are considered allowable costs for the cost report and will be included in the calculation of the reimbursement rate for a patient visit at an FQHC/RHC.

Refer to the Code of Colorado Regulations (1- CCR 2505-10, Section 8.095) for more information.

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

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Telemedicine Originator Claim Example

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Telemedicine Distance Claim Example

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for more information on timely filing policy, including the resubmission rules for denied claims.

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Telemedicine Revisions Log