Last updated 02/02/2023
Definitions
“Telemedicine is the use of medical information about a patient that is exchanged from one site to another via electronic communications to provide medical care to a patient in circumstances in which face-to-face contact is not necessary. In this instance, a physician or other qualified medical professional has determined that medical care can be provided via electronic communication with no loss in the quality or efficacy of the care.”
“Electronic communication means the use of interactive telecommunication equipment that typically includes audio and video equipment permitting two-way, real-time interactive communication between the patient and the physician or practitioner at the referring site. Telemedicine includes consultation, diagnostic, and treatment services.”
SOURCE: SC Health and Human Svcs. Dept., Physicians Provider Manual, p. 27-28 (Oct. 2022). (Accessed Feb. 2023).
Last updated 02/02/2023
Email, Phone & Fax
No reimbursement for email.
No reimbursement for telephone.
No reimbursement for FAX.
No reimbursement for video cell phone interactions.
SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 157 (Oct. 2022). (Accessed Feb. 2023).
FQHCs/RHCs Behavioral Health Services
Family Therapy: Billing for telephone calls is not allowed.
SOURCE: SC Health and Human Svcs. Dept. Federally Qualified Health Center Behavioral Health Services Provider Manual, p. 26, (Jan. 2023) & Rural Health Clinic Behavioral Health Services Provider Manual, p. 25, (Jan. 2020), (Accessed Feb. 2023).
Medicaid Targeted Case Management
Electronic visual encounters (e.g., Skype, teleconferencing or other media) with the beneficiary are not considered a face-to-face contact and will be reimbursed at the T1016 MTCM encounter rate.
- A telephone contact is in lieu of a face-to-face contact when environmental considerations preclude a face-to-face encounter, for the purpose of rendering one or more MTCM components. Documentation must include details precluding a face-to-face encounter.
- A relevant email contact via secured transmittal, on behalf of the beneficiary for the purpose of rendering one or more MTCM components.
For Medicaid purposes, a face-to-face contact is preferable with phone and/or email contact being acceptable if necessary.
SOURCE: SC Health and Human Svcs. Dept., Medicaid Targeted Case Management Provider Guide, p. 21 (Apr. 2021). (Accessed Feb. 2023).
Dental Telephonic Encounters
As of July 1, 2021, patient triage and care coordination via telephonic or telehealth encounter, along with oral evaluations performed in conjunction with the telehealth encounters, will no longer be allowed.
Source: SC Health and Human Svcs. Dental Services Provider Manual. (Jan. 2023). Pg. 79. (Accessed Feb. 2023).
Licensed Independent Practitioner’s Rehabilitative Services.
Service Plan Development (SPD) is a face-to-face or telephonic interaction between the beneficiary and a qualified clinical professional or a team of professionals.
Crisis Management (CM) is a face-to-face, or telephonic, short-term service is to assist a beneficiary, who is experiencing a marked deterioration of functioning related to a specific precipitant, in restoring his/her level of functioning and/or to stabilize the beneficiary.
Telephonic interventions are provided either to the beneficiary or on behalf of the beneficiary to collect an adequate amount of information to provide appropriate and safe services, stabilize the beneficiary, and prevent a negative outcome
When necessary/appropriate, consultation shall only include telephone or face-to-face contact by a Psychologist/LPES to the family, school, or another health care provider to interpret or explain the results of psychological testing and/or evaluations related to the care and treatment of the beneficiary. The Psychologist/LPES must document the recommended course of action.
Telephone contact related to office procedures or appointment times are not covered.
Rehabilitative Behavioral Health Services Provider Manual
Crisis Management: The purpose of this face-to-face or telephonic short-term service is to assist a beneficiary who is
experiencing urgent or emergent marked deterioration of functioning related to a specific precipitant
in restoring his or her level of functioning.
Face-to-face inventions require immediate response by a clinical professional and include:
Telephonic interventions are provided either to the beneficiary or on behalf of the beneficiary to
collect an adequate amount of information to provide appropriate and safe services, stabilize the
beneficiary, and prevent a negative outcome.
SOURCE: SC Health and Human Svcs. Dept. Rehabilitative Behavioral Health Services Provider Manual, p. 56-57. (Jan. 2023). (Accessed Feb. 2023).
Last updated 02/02/2023
Live Video
POLICY
South Carolina Medicaid will reimburse for live video and covers telemedicine when the service is medically necessary and under the following circumstances:
- The medical care is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s need; and
- The medical care can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide.
SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 29 (Oct. 2022). (Accessed Feb. 2023).
If there are technological difficulties in performing a medical assessment or problems in a beneficiaries’ understanding of telemedicine, face-to-face care must be provided instead.
SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 28 (Oct. 2022). (Accessed Feb. 2023).
Interactive audio and video telecommunication must be used; permitting encrypted communication between the distant site physician or practitioner and the Medicaid beneficiary. The telecommunication service must be secure and adequate to protect the confidentiality and integrity of the telemedicine information transmitted.
The telemedicine equipment and transmission speed and image resolution must be technically sufficient to support the service billed. Staff involved in the telemedicine visit must be trained in the use of the telemedicine equipment and competent in its operation.
Reimbursement to the health professional delivering the medical service is the same as the current fee schedule amount for the service provided. See appropriate professional manuals for CPT codes. Codes must be billed along with the telemedicine GT modifier.
To qualify for reimbursement, interactive audio and video equipment that permits two-way real-time or near real-time communication with the client, consultant, interpreter, and referring clinician.
Additional requirements include:
- Reimbursement requires the “real-time” presence of a client.
- Reimbursement is available for psychiatric diagnosis assessment with Medicaid and medical evaluation and management codes.
- GT modifier must be used when billing the for telepsychiatric services.
- All equipment must operate at a minimum communication transfer rate of 384 kbps.
- Telepsychiatry reimbursement is not available for the following MH services; injectable, NS, CI Individual Family, Group and Multiple FP and Psychological Testing which require “hands on” encounters, Mental Health Assessment by Non-Physician and SPD.
SOURCE: SC Health and Human Svcs. Dept. Community Mental Health Services Provider Manual, p. 30. (Jan. 2023). (Accessed Feb. 2023).
ELIGIBLE SERVICES/SPECIALTIES
Eligible services include consultation, diagnostic, and treatment services:
- Office or other outpatient visits;
- Inpatient consultation;
- Individual psychotherapy;
- Pharmacologic management
- Psychiatric diagnostic interview examination;
- Neurobehavioral status examination;
- Electrocardiogram interpretation and report only;
- Echocardiography.
Services provided by allied health professionals are not covered.
Telemedicine services are not an expansion of covered services, but an option for the delivery of certain covered services.
SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 28-30, 157 (Oct. 2022). (Accessed Feb. 2023).
Local education manual refers providers to the physician Services Provider Manual for information regarding coverage and billing for telemedicine.
SOURCE: SC Health and Human Svcs. Dept. Local Education Provider Manual, p. 22. (Jan. 2023). (Accessed Feb. 2023).
Medicaid Targeted Case Management
Electronic visual encounters (e.g., Skype, teleconferencing or other media) with the beneficiary are not considered a face-to-face contact and will be reimbursed at the T1016 MTCM encounter rate.
SOURCE: SC Health and Human Svcs. Dept., Medicaid Targeted Case Management Provider Guide, p. 21 (Apr. 2021). (Accessed Feb. 2023).
Telepsychiatry
Psychiatric Diagnostic assessment with medical services to assess or monitor the client’s psychiatric and/or physiological status may be provided via live video telepsychiatry. See manual for specific requirements.
SOURCE: SC Health and Human Svcs. Dept. Community Mental Health Services Provider Manual, p. 30 (Jan. 2023). (Accessed Feb. 2023).
Autism Spectrum Disorder
Telehealth is not covered.
SOURCE: SC Health and Human Svcs. Autism Spectrum Disorder Provider Manual, p. 19 (Jan. 2023). (Accessed Feb. 2023).
Dental Telephonic or Telehealth Encounters
As of July 1, 2021, patient triage and care coordination via telephonic or telehealth encounter, along with oral evaluations performed in conjunction with the telehealth encounters, will no longer be allowed.
SOURCE: SC Health and Human Svcs. Dental Services Provider Manual. (Jan. 2023), Pg. 79. (Accessed Feb. 2023).
ELIGIBLE PROVIDERS
Distant site eligible, reimbursed providers:
- Physicians;
- Nurse practitioners;
- Physician Assistants.
A consultant site means the site at which the specialty physician or practitioner providing the medical care is located at the time the service is provided via telemedicine. The health professional providing the medical care must be currently and appropriately licensed in South Carolina and located within the South Carolina Medical Service Area (SCMSA), which is defined as the State of South Carolina and areas in North Carolina and Georgia within 25 miles of the South Carolina State border.
SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 28-29. (Oct. 2022) (Accessed Feb. 2023).
The RHCs and FQHCs would bill an encounter code when operating as the consulting site. Only one encounter code can be billed for a DOS. Both provider types will use the appropriate encounter code for the service along with the “GT” modifier (via interactive audio and video telecommunications system) indicating interactive communication was used.
SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 215. (Oct. 2022). (Accessed Feb. 2023).
ELIGIBLE SITES
Eligible originating (referring) sites:
- Practitioner offices (physician, NP, CNM or PA);
- Hospitals (inpatient and outpatient);
- Rural Health Clinics;
- Federally Qualified Health Centers;
- Community Mental Health Centers;
- Public Schools;
- Act 301 Behavioral Health Centers.
Referring sites (also known as originating sites) are the location of an eligible Medicaid beneficiary at the time the service being furnished via a telecommunication system occurs and must be located in the South Carolina Medical Service Area, which is the state of SC and areas in NC and GA within 25 miles of the SC border.
SOURCE: SC Health and Human Svcs. Dept., Physicians Provider Manual, p. 28 (Oct. 2022). (Accessed Feb. 2023).
Local Education Agency Manual refers providers to the Physician Manual Policy.
SOURCE: Local Education Manual, p. 22. (Jan. 2023). (Accessed Feb. 2023).
An appropriate certified or licensed health care professional at the referring site is required to present (patient site presenter) the beneficiary to the physician or practitioner at the consulting site and remain available as clinically appropriate.
SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 30 (Oct. 2022). (Accessed Feb. 2023).
GEOGRAPHIC LIMITS
A consultant site means the site at which the specialty physician or practitioner providing the medical care is located at the time the service is provided via telemedicine. The health professional providing the medical care must be currently and appropriately licensed in South Carolina and located within the South Carolina Medical Service Area (SCMSA), which is defined as the State of South Carolina and areas in North Carolina and Georgia within 25 miles of the South Carolina State border.
FACILITY/TRANSMISSION FEE
The referring site is only eligible to receive a facility fee for telemedicine services. Claims are submitted with HCPCS code. If a provider from the referring site performs a separately identifiable service for the beneficiary on the same day as telemedicine, documentation for both services must be clearly and separately identified in the beneficiary’s medical record, and both services are eligible for full reimbursement.
RHCs and FQHCs are eligible to receive a facility fee for telemedicine services when operating as the referring site. Claims must be submitted with the HCPCS code for Telemedicine originating site facility fee. They may not bill the encounter code if these are the only services being rendered.
Hospital providers are eligible to receive a facility fee for telemedicine when operating as the referring site. Claims must be submitted with the appropriate telemedicine revenue code.
Last updated 02/02/2023
Miscellaneous
If a beneficiary is a minor child, a parent and/or guardian must present the child for telemedicine services unless otherwise exempted by State or Federal law. The parent and/or guardian need not attend the telemedicine session unless attendance is therapeutically appropriate.
Documentation in the medical records must be maintained at the referring and consulting locations to substantiate the service provided. A request for a telemedicine service from a referring provider and the medical necessity for the telemedicine service must be documented in the beneficiary’s medical record. Documentation must indicate the services were rendered via telemedicine. All applicable documentation requirements for services delivered face-to-face also apply to services rendered via telemedicine.
The beneficiary must have access to all transmitted medical information, with the exception of live interactive video, as there is often no stored data in such encounters.
Last updated 02/02/2023
Overview
South Carolina Medicaid reimburses for live video under certain circumstances. Store-and-forward is not reimbursed as it does not meet established conditions for the use of telemedicine. South Carolina Medicaid reimburses for home health monitoring through the Home Aging Program for some conditions when a patient is eligible.
