sc medicaid virtual visit

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Related Resources

• State Medicaid & CHIP Telehealth Toolkit: February 2024
• Medicaid & CHIP Telehealth Toolkit: Tools for States  
• State Medicaid & CHIP Telehealth Toolkit: COVID-19 Version
• State Medicaid & CHIP Telehealth Toolkit: COVID-19 Version, Supplement #1  
• CMCS Informational Bulletin: Rural Health Care and Medicaid Telehealth Flexibilities, and Guidance Regarding Section 1009 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act
• Report to Congress: Reducing Barriers to Using Telehealth and Remote Patient Monitoring for Pediatric Populations under Medicaid
• Reimbursement for Medicaid for Services Delivered Via Telehealth

Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance. At one time, telehealth in Medicaid had been referred to as telemedicine.

Telehealth seeks to improve a patient's health by permitting two-way, real-time interactive communication between the patient and the physician or practitioner at the distant site. This  communication often requires  the use of interactive telecommunications equipment that can include both audio and video components, but can also be conducted via audio-only, as states deem appropriate.

Telehealth includes such technologies as telephones, electronic mail systems, and remote patient monitoring devices, which are used to collect and transmit patient data for monitoring and interpretation.

State Telehealth Flexibilities

For most Medicaid benefits, federal Medicaid law and regulations do not specifically address telehealth delivery methods or the criteria for implementation of telehealth.  As a result, states have broad flexibility in designing the parameters of telehealth delivery methods to furnish services. However, underlying services must continue to meet the requirements of the overarching provisions in Title XIX of the Social Security Act (the Act), regulations, the federal policy framework of the covered Medicaid benefit, and the parameters of the state’s CMS-approved Medicaid state plan or a subsequent state plan amendment (SPA). Where Medicaid law or regulations set forth telehealth delivery requirements for specific benefits, those requirements must be observed. For example, the Community First Choice (CFC) Option at 1915(k) has general requirements for using telehealth for performing the assessment of need (§441.535), but does not have requirements for other CFC activities that could be performed using telehealth.

CMS Approach to Reviewing Telehealth SPAs

Unless required by regulation or policy, states are not required to submit a (separate) SPA for coverage or reimbursement of Medicaid coverable services delivered through telehealth if they decide to reimburse for services delivered through telehealth in the same way/amount that they pay for face-to-face services.

States must submit a (separate) reimbursement (attachment 4.19B) SPA if they want to provide reimbursement for services or components of services delivered through telehealth differently than is currently being reimbursed for face-to-face services.

States may submit a coverage SPA to better describe the services they choose to cover through telehealth, such as which providers/practitioners are identified by the state to use telehealth to deliver services; where it is provided; how it is provided, etc. In this case, and in order to avoid unnecessary SPA submissions, it is recommended that a brief description of the framework of telehealth may be placed in an introductory section of the state plan, e.g., Section 3 – Services: General Provisions 3.1 Amount, Duration and Scope of Services, and then a reference made to coverage through telehealth in the applicable benefit sections of the state plan. For example, in the physician section it might say that dermatology services can be delivered via telehealth provided all state requirements related to telehealth as described in the state plan are otherwise met.

Definitions

Requirements.

• Store-and-Forward

Remote Patient Monitoring

• Email, Phone & Fax

Consent Requirements

Out of state providers, miscellaneous, online prescribing.

• Cross-State Licensing

Licensure Compacts

• Professional Boards Standards

Definition of Visit

Modalities allowed, same day encounters, eligible originating site, eligible distant site, facility fee, home eligible, patient-provider relationship.

• Connecticut
• District of Columbia
• Massachusetts
• Mississippi
• New Hampshire
• North Carolina
• North Dakota
• Pennsylvania
• Puerto Rico
• Rhode Island

South Carolina

• South Dakota
• Virgin Islands
• West Virginia
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• Pending legislation
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• Policy trend maps
• What is telehealth?
• Resources & reports
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• National Telehealth Resource Center Partners
• California Telehealth Policy Coalition
• Resources & Reports

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

MEDICAID REIMBURSEMENT

• Live Video: Yes
• Store-and-Forward: Yes* (CTBS Only)
• Remote Patient Monitoring: Yes
• Audio Only: Yes

PRIVATE PAYER LAW

• Law Exists: No
• Payment Parity: No

PROFESSIONAL REQUIREMENTS

• Licensure Compacts: ASLP-IC, EMS, NLC, OT, PSYPACT, PTC
• Consent Requirements:  No
• Originating sites explicitly allowed for Live Video: Yes
• Distant sites explicitly allowed for Live Video: Yes
• Store and forward explicitly reimbursed: Yes* (CTBS Only)
• Audio-only explicitly reimbursed: Yes
• Allowed to collect PPS rate for telehealth: No

STATE RESOURCES

• Medicaid Program: South Carolina Medicaid
• Administrator: South Carolina Health and Human Services Dept.
• Regional Telehealth Resource Center: Southeastern Telehealth Resource Center

Private Payer

Last updated 02/08/2024

No Reference Found

SERVICE PARITY

Payment parity.

SOURCE:   SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 35 (Feb. 2024). (Accessed Feb. 2024).

Last updated 02/07/2024

Telehealth is defined as the provision of healthcare via electronic communications technology between a provider in one location and a patient in another location without loss of quality of 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 provider at the referring site.

Though there are differences in the definitions of telehealth and telemedicine, the two terms are generally used interchangeably, and SCDHHS will reference telehealth in this and other provider manuals addressing the provision of services via electronic communications.

Telehealth includes consultation, diagnostic and treatment services. Telehealth as a service delivery option, in some cases, can provide beneficiaries with increased access to specialists, better continuity of care, and eliminate the hardship of traveling extended distances.

SOURCE: SC Health and Human Svcs. Dept., Physicians Provider Manual, p. 32 (Feb. 2024). (Accessed Feb. 2024).

Email, Phone & Fax

When audio/visual telehealth is not available, SCDHHS will continue to reimburse providers for one year beyond the end date of the current federal PHE for the audio-only CPT codes included in the source referenced below  (see bulletin).

Reimbursement for the CPT codes included will continue to be limited to encounters with established patients as described in Medicaid bulletin 20-004 when rendered by a physician, nurse practitioner, physician assistant or licensed independent practitioner (LIP). Additional services that can be provided via audio-only during this extended time period include certain services for BabyNet-enrolled Children.

SOURCE:  SC Dept. of Health and Human Services. Medicaid Bulletin 22-005. (May 2023). (Accessed Feb. 2024).

Services that are eligible for telehealth reimbursement include consultation, office visits, individual psychotherapy, pharmacologic management, and psychiatric diagnostic interview examinations and testing, delivered via a telecommunication system, and audio-only (telephonic) care (available for established patients only).

While SC Medicaid includes the above mention of audio-only coverage, and certain telephonic codes are also noted as covered in the Telehealth Fee Schedule , the manual also states that the following interactions do not constitute reimbursable telehealth or telepsychiatry services and will not be reimbursed:

• Telephone conversations
• Email messages
• Video cell phone interactions
• Facsimile transmissions
• Services provided by allied health professionals

SOURCE:  SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 34, 158-159 (Feb. 2024). (Accessed Feb. 2024).

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, (Feb. 2023) & Rural Health Clinic Behavioral Health Services Provider Manual, p. 25, (Jan. 2020), (Accessed Feb. 2024).

Despite the above exclusion, according to a recent Medicaid bulletin, telehealth services rendered through an FQHC or RHC for certain audio-only CPT codes will be reimbursed.

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. 23 (Nov. 2023). (Accessed Feb. 2024).

Behavioral Health Services

Telehealth and audio-only modalities are available for select behavioral health services including telephonic assessments, crisis intervention, individual and family psychotherapy, psychiatric diagnostic assessments, nursing services, service plan development, and medication management. These services are available for providers enrolled under CHMC, RBHS, or LIP categories and include physicians, nurse practitioners, and physician assistants, Licensed Psychologists (and postdoctoral pending licensure), Licensed Professional Counselors (and LPC-associate), Licensed Independent Social Workers, Licensed Marriage and Family Therapists (and LMFT-associate), and Licensed Psycho-Educational Specialists.

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 interventions require immediate response by a clinical professional and include telephonic interventions that 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. 61-62, 91. (Jan. 2024); SC Health and Human Svcs. Dept. Licensed Independent Practitioner’s Rehabilitative Provider Manual, p. 14, 20-21. (Nov. 2023). (Accessed Feb. 2024).

Some services rendered by LIPs may be provided via telehealth or audio-only modalities with the use of a GT modifier. These services include audio-only assessments for established patients, and psychotherapy and psychiatric evaluations for new and established patients.

Psychological Test and Evaluation – 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.

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.

Telephone contact related to office procedures or appointment times are not covered.

SOURCE:   SC Health and Human Svcs. Dept. Licensed Independent Practitioner’s Rehabilitative Provider Manual, p. 15, 18, 22. (Nov. 2023). (Accessed Feb. 2024).

Children and adult beneficiaries are eligible to receive services via telehealth modality under the State Plan benefit (authority).

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.
• No equally effective, more conservative or less costly treatment is available Statewide

The following conditions apply to all services rendered via telehealth.

• The beneficiary must be present and participating in the telehealth visit.

The referring provider must provide pertinent medical information and/or records to the consulting provider via a secure transmission.

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 telehealth information transmitted.

The telehealth equipment and transmission speed and image resolution must be technically sufficient to support the service billed. Any staff involved in the telehealth visit must be trained in the use of the telehealth equipment and competent in its operation.

A trained healthcare professional at the referring site (patient site presenter) is required to present the beneficiary to the provider at the consulting site and remain available as clinically appropriate (this condition is waived when the referring site is the patient home).

If the beneficiary is a minor (under 18 years old), a parent and/or guardian must present the minor for telehealth service unless otherwise exempted by State or Federal law. The parent and/or guardian need not attend the telehealth session unless attendance is therapeutically appropriate.

• The beneficiary retains the right to withdraw from the telehealth visit at any time.

All telehealth activities must comply with the requirements of HIPAA: Standards for Privacy of individually identifiable health information and all other applicable State and Federal Laws and regulations.

• The beneficiary has access to all transmitted medical information, except for live interactive video, as there is often no stored data in such encounters.
• The provider at the distant site must obtain prior approval for service when services require prior approval, based on service type or diagnosis.

Reimbursement to the health professional delivering the medical service is the same as the current fee schedule amount for the service provided. Consulting site physicians and practitioners submit claims for telehealth or telepsychiatry services using the appropriate CPT code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications system”. By coding and billing the “GT” modifier with a covered telehealth procedure code, the consulting site physician and/or practitioner certifies that the beneficiary was present at the referring site when the telehealth service was furnished. Fee schedules are located on the SCDHHS website at http://www.scdhhs.gov.

SOURCE:  SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 32-35, 210. (Feb. 2024). (Accessed Feb. 2024).

Telepsychiatry

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. 2024).

ELIGIBLE SERVICES/SPECIALTIES

Telehealth services are not an expansion of Medicaid-covered services but an option for the delivery of certain covered services. Quality of health care must be maintained regardless of the mode of delivery. Telehealth includes consultation, diagnostic and treatment services.

Services that are eligible for reimbursement include consultation, office visits, individual psychotherapy, pharmacologic management, and psychiatric diagnostic interview examinations and testing, delivered via a telecommunication system.

Office and OP visits that are conducted via telehealth are counted towards the applicable benefit limits for these services.

Well-care visits conducted via telehealth must be billed with the appropriate EPSDT code and a GT modifier.

Services provided by allied health professionals are not covered.

SOURCE:  SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 32, 34, 159, 227 (Feb. 2024). (Accessed Feb. 2024).

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. 2024).

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. 2024).

Applied Behavior Analysis 

SCDHHS will continue to reimburse providers for the ABA services described in the bulletin referenced in the source below when rendered through telehealth for one year beyond the end date of the current federal PHE. These flexibilities will be extended for remote supervision of registered behavior technicians (RBTs) who provide service in a face-to-face setting and consultation of parent-directed activities via telehealth for the CPT codes listed as described in Medicaid bulletin 20-011 . These flexibilities will be extended for encounters that include both audio and visual components.

Authorized synchronous audio/visual supervision of RBTs and other therapists is available using telehealth for established patients. Services provided via telehealth are to be reimbursed in lieu of, not in addition to, those provided face-to-face and reimbursed in a manner consistent with the authorities and limitations detailed in the State Plan and this provider manual. Use of a GT modifier will be required for any telehealth visits in addition to any other modifier(s) required for the service. The GT modifier will be listed in the secondary modifier position, with any other required modifier listed in the primary modifier position.

If in-person interaction with an RBT or other therapist is not feasible, services below may be provided via telehealth for consultation by providers authorized to practice independently, when provided through a parent or family member.

SOURCE:  SC Health and Human Svcs. Autism Spectrum Disorder Provider Manual, p. 18 (Jan. 2024). (Accessed Feb. 2024).

Behavioral Health

Prior to the COVID-19 PHE, SCDHHS’ Medicaid program covered a broad array of behavioral health services that were eligible for reimbursement when delivered using audio and visual interactions to ensure access to services in a variety of settings. SCDHHS will continue to augment the state’s existing behavioral health telehealth benefit and extend the flexibilities included below for one year beyond the end date of the current federal PHE. Services described within the bulletin referenced in the source below are eligible for reimbursement when delivered by LIPs and associate-level licensed practitioners as described in Medicaid bulletins 20-009 ,  20-014  and  20-016 . Services rendered through an FQHC or RHC for the CPT codes listed will be reimbursed. Services described will also be continued for this period for mental health professional master’s level personnel employed by other state agencies.

Developmental Evaluation Center (DEC) Screenings

SCDHHS will continue to reimburse DECs for services rendered through telehealth for one year beyond the end date of the current federal PHE. These flexibilities will be extended for encounters that include both audio and visual components. As specified in the  SCDHHS memo issued April 16, 2020 , services rendered by a physician, NP, PA or psychologist for the below Healthcare Common Procedure Coding System (HCPCS) codes will be reimbursed subject to the same duration requirements and service limits as services delivered face-to-face.

Addiction and Recovery-related Services

SCDHHS will continue to reimburse for management of medication-assisted treatment (MAT) services and services rendered by Act 301 local alcohol and drug abuse authorities (local authorities) delivered through telehealth for one year beyond the end date of the current federal PHE. These continued flexibilities apply to the procedure codes listed below for the services and provider types described in the  memo SCDHHS issued April 17, 2020 , and Medicaid bulletin  20-017  with the exception of audio-only telephonic coverage of MAT services, which will sunset with the end of the current federal PHE.

Telehealth Services for BabyNet-enrolled Children

SCDHHS will continue to reimburse providers for early intervention services and development of individualized family service plans (IFSPs) rendered through telehealth. These flexibilities will be extended for one year beyond the end date of the current federal PHE. Services for the procedure codes listed below will continue to be reimbursed when rendered as described in Medicaid bulletin  20-010  and the  Medicaid alert dated July 9, 2020 . Interpretation services as described in Medicaid bulletin  20-010  will also continue for one year beyond the end date of the current federal PHE. Additional billing guidance for these services is available in the  memo issued by SCDHHS on April 30, 2020 .

In addition to the physical and speech therapy services described above, providers can also continue to be reimbursed for occupational therapy rendered through telehealth for children enrolled in the BabyNet program as described in Medicaid bulletin  20-008 .

Child Well-care and Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Visits

SCDHHS will continue to reimburse providers for child well-care and EPSDT visits rendered through telehealth. These continued flexibilities apply to the policy changes described in Medicaid bulletin  20-015  for encounters that include both audio and visual components.

Physical and Speech Therapy Services

SCDHHS will continue to reimburse for physical and speech therapy services that include both audio and visual components for one year beyond the end date of the current federal PHE. These continued flexibilities apply to physical and speech therapy services rendered by the provider types and procedure codes listed below for services described in Medicaid bulletins  20-008  and  20-016 , with the exception of services provided as audio-only telephonic services, which will no longer be reimbursable upon expiration of the current federal PHE.

Occupational Therapy

Occupational therapy services described in Medicaid bulletins 20-008  and  20-016  will continue to be eligible for reimbursement when delivered via telehealth that includes both audio and visual components for one year beyond the end date of the current federal PHE. Initial evaluations still must be performed in a face-to-face encounter to be eligible for reimbursement.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin Update on Occupational Therapy Telehealth Flexibilities. (Oct. 2022). (Accessed Feb. 2024).

Nutritional Counseling Services

Nutritional counseling services are allowed to be performed via telehealth. A telehealth encounter must be billed with GT modifier, and it counts towards the twelve (12) hours of combined medical nutrition therapy services provided to a patient per fiscal year. Services delivered in-person or via telehealth by the same provider type will be reimbursed at the same rate.

For Federally Qualified Health Center Services, medical nutrition therapy is billable under the encounter rate. If the beneficiary is seen by a physician or mid-level provider and dietitian on the same day, one encounter can be billed for the services received that day.

For Rural Health Center Services, nutritional counseling services are also allowed to be performed via telehealth. However, medical nutrition therapy is not allowed to be billed using the encounter rate. All providers and dietitians are required to bill the appropriate CPT codes with a primary diagnosis code. The provider can either schedule the patient for an independent visit or may bill the initial medical nutrition therapy visit on the same day as a routine physical exam or E&M service. The subsequent individual or group nutrition therapy must be scheduled as independent visits. Medical nutrition therapy services performed in a RHC must be billed under the performing provider’s group NPI, not allowed to be billed under the RHC NPI.

SOURCE: SC Health and Human Svcs. Dept. Medicaid Bulletin 23-060, Dec. 2023 &  SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 217-218, 260, 263-264. (Feb. 2024). (Accessed Feb. 2024).

Interprofessional Consultation

SCDHHS will reimburse providers for interprofessional consultation services as distinct services under the Medicaid physician fee schedule.

Interprofessional consultation is defined as a situation in which the patient’s treating physician or other qualified health care practitioner (hereafter referred to as the treating practitioner) requests the opinion and/or treatment advice of a physician or other qualified health care practitioner with specific specialty expertise (hereafter referred to as the consulting practitioner) to assist the treating practitioner with the patient’s care.

Interprofessional consultation is intended to expand access to specialty care and foster interdisciplinary input on patient care. It is not intended to be a replacement for direct specialty care when such care is clinically indicated. Reimbursement of interprofessional consultation is permissible, even when the beneficiary is not present, as long as the consultation is for the direct benefit of the beneficiary. The consulting provider must be an enrolled Medicaid provider. Interprofessional consultation services may be provided via telehealth and reimbursed with the use of the appropriate modifier.

SOURCE: SC Health and Human Svcs. Dept. Medicaid Bulletin 23-063, Dec. 2023 &  SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 85-86. (Feb. 2024). (Accessed Feb. 2024).

ELIGIBLE PROVIDERS

Providers who meet the Medicaid credentialing requirements and are currently enrolled with the South Carolina Medicaid program are eligible to bill for telehealth and telepsychiatry when the service is within the scope of their practice. The referring provider is the provider who has evaluated the beneficiary, determined the need for a consultation, and has arranged the services of the consulting provider for the purpose of consultation, diagnosis and/or treatment. The consulting provider is the provider who evaluates the beneficiary via telehealth mode of delivery upon the recommendation of the referring provider.

Practitioners at the distant site who may furnish and receive payment of covered telehealth services are:

• Licensed Independent Practitioners (and associates)
• Physical, occupational, and speech therapists

A licensed physician, NP, PA, licensed psychologist, licensed professional counselor, licensed independent social worker, and licensed marriage and family counselor may provider telepsychiatry services.

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 telehealth. The health professional providing the medical care must be currently and appropriately licensed in South Carolina. FQHC and RHC providers are eligible to serve as consulting site providers for telehealth services.

Consulting site physicians and practitioners submit claims for telehealth or telepsychiatry services using the appropriate CPT code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications system”. By coding and billing the “GT” modifier with a covered telehealth procedure code, the consulting site physician and/or practitioner certifies that the beneficiary was present at originating site when the telehealth service was furnished.

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. 32-34, 215. (Feb. 2024) (Accessed Feb. 2024).

SCDHHS will continue to reimburse FQHCs and RHCs for services rendered through telehealth. This extension applies to the flexibilities announced in Medicaid bulletin  20-007 and to the services described within the bulletin referenced in the source below.

ELIGIBLE SITES

Eligible originating (referring) sites:

• Practitioner offices (physician, NP, CNM, PA or LIP);
• Hospitals (inpatient and outpatient);
• Rural Health Clinics;
• Federally Qualified Health Centers;
• Community Mental Health Centers;
• Public Schools;
• Act 301 Behavioral Health Centers
• Patient home

A referring site (also known as an originating site) is the location of an eligible Medicaid beneficiary at the time the service being furnished via a telecommunication system occurs. Medicaid beneficiaries are eligible for telehealth services only if they are presented from a referring site located in the SCMSA. Referring site presenters may be required to facilitate the delivery of this service. Referring site presenters should be a person knowledgeable in how the equipment works and able to provide clinical support if needed during a session.

A trained 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 (this condition is waived when the referring site is the patient home).

SOURCE:  SC Health and Human Svcs. Dept., Physicians Provider Manual, p. 33, 35 (Feb. 2024). (Accessed Feb. 2024).

Local Education Agency Manual refers providers to the Physician Manual Policy.

SOURCE:  Local Education Manual, p. 22. (Jan. 2023). (Accessed Feb. 2024).

SCDHHS will waive referring site restrictions that existed prior to the COVID-19 PHE, which will allow providers to be reimbursed for services delivered via telehealth to Healthy Connections Medicaid members regardless of the members’ location as described in Medicaid bulletin  20-005 . This flexibility applies to the evaluation and management (E/M) Current Procedural Terminology (CPT) codes listed in the bulletin referenced in the source below for services rendered by a physician, nurse practitioner, or physician assistant. This flexibility will be made permanent for evaluation and management encounters that include both audio and visual components.

GEOGRAPHIC LIMITS

A consultant site (also called the distant site) is the site at which the provider is located at the time the telehealth service. The provider performing the medical care must be currently and appropriately licensed in South Carolina. FQHC and RHC providers are eligible to serve as consulting site providers for telehealth services.

SOURCE:   SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 32-33. (Feb. 2024). (Accessed Feb. 2024).

FACILITY/TRANSMISSION FEE

The referring site is only eligible to receive a facility fee for telehealth services. Claims must be submitted with an appropriate HCPCS code (telehealth originating site facility fee). If a provider from the referring site performs a separately identifiable service for the beneficiary on the same day as telehealth, 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 reimbursement for a facility fee for the telehealth services when operating as the referring site. Claims must be submitted with the HCPCS code for telehealth originating site facility fee. When serving as the referring site, the RHCs and FQHCs cannot bill the encounter code if these are the only services being rendered.

Hospital providers are eligible to receive reimbursement for a facility fee for telehealth when operating as the referring site. Claims must be submitted with the appropriate telehealth revenue code. There is no separate reimbursement for telehealth services when performed during an inpatient stay, OP clinic or ER visit, or OP surgery, as these are all-inclusive payments.

SOURCE:   SC Health and Human Svcs. Dept., Physicians Provider Manual, p. 215 (Feb. 2024). (Accessed Feb. 2024).

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.

Documentation in the medical records must be maintained at the referring and consulting locations to substantiate the service provided. A request for a telehealth service from a referring provider and the medical necessity for the telehealth service must be documented in the beneficiary’s medical record. Documentation must indicate the services were rendered via telehealth. All applicable documentation requirements for services delivered face-to-face also apply to services rendered via telehealth.

SOURCE:   SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 35, 192 (Feb. 2024). (Accessed Feb. 2024).

The health professional providing the medical care must be currently and appropriately licensed in South Carolina.

SOURCE:  SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 32-33 (Feb. 2024). (Accessed Feb. 2024).

South Carolina Medicaid reimburses for live video under certain circumstances. Store-and-forward does not appear to be reimbursed as it does not meet certain established conditions for coverage. However, CPT Code G2010 (remote images submitted by a patient) is listed as reimbursed for established patients.

South Carolina Medicaid reimburses for home health monitoring through the Home Aging Program for some conditions when a patient is eligible. Certain audio-only codes for particular providers will continue to be reimbursed for one year beyond the end of the federal public health emergency, until May 11, 2024.

An order or referral is required for South Carolina Medicaid Telemonitoring services.

SOURCE:   SC Health and Human Svcs. Dept. Provider Administrative and Billing Manual, p. 12-13 (May 2023). (Accessed Feb. 2024).

PROVIDER LIMITATIONS

Other restrictions, store and forward.

G2010 (Remote image submitted by a patient) is listed as reimbursed for established patients.

South Carolina Medicaid coverage guidelines appear to exclude reimbursement for store-and-forward due to the requirements that the beneficiary must be present and participating in the visit and interactive audio and video telecommunication must be used.

SOURCE:   SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 34-35 (Feb. 2024). (Accessed Feb. 2024).

TRANSMISSION FEE

Professional Requirements

Cross state licensing.

The physician must be licensed in South Carolina; however, they do not need to reside in South Carolina.

A licensee residing in South Carolina who intends to practice medicine via telemedicine to treat or diagnose patients outside of South Carolina shall comply with other state licensing boards.

SOURCE:   SC Code Annotated Sec. 40-47-37(C)(9). (Accessed Feb. 2024).

A person providing social work services to a client in this State, through telephonic, electronic, or other means, regardless of the location of the social worker, who is not licensed or registered in this State, is practicing without a license. A social worker licensed by this State may provide services through these means to a client in this State within their appropriate scope of practice.

SOURCE: SC Code Annotated Sec. 40-63-30(B) . (Accessed Feb. 2024).

For purposes of this section, ‘behavioral telehealth’ means the practice of Independent Social Work‑CP using electronic communications, information technology, or other means between a registrant located outside this State and a client located in this State with or without an intervening practitioner. A behavioral telehealth provider has the duty to practice in a manner consistent with his scope of practice and the prevailing professional standard of practice for an Independent Social Work‑CP who provides in‑person social work services to clients in this State.

An Independent Social Work‑CP who holds an active license to provide independent social work services in another state or jurisdiction may provide independent social work services using behavioral telehealth to a client located in this State if the individual is registered with the board and provides the services within the applicable scope of practice established by this State.

To be registered, the individual must:

• complete an application in the format prescribed by the board;
• be licensed with an active, unencumbered license that is issued by another state, the District of Columbia, or a possession or territory of the United States and that is substantially similar to a license issued by South Carolina to an Independent Social Worker‑CP;
• have not been the subject of disciplinary action relating to his license during the five‑year period immediately prior to the submission of the application; and
• pay a ten dollar fee.

The website of a behavioral telehealth registrant must prominently display a hyperlink to the board’s website list of registrants and related information.

The individual may not register under this section if his license to provide social work services is subject to a pending disciplinary investigation or action or has been revoked in any state or jurisdiction. A social worker registered under this section must notify the board of restrictions placed on his license to practice, or any disciplinary action taken or pending against him, in any state or jurisdiction. The notification must be provided within five business days after the restriction is placed or disciplinary action is initiated or taken.

The board shall publish on its website a list of all registrants and include, to the extent applicable, each registrant’s name, address, out‑of‑state social work license type with the license number, and South Carolina behavioral telehealth registration number.

The board may take disciplinary action against an out‑of‑state registrant registered under this section if the individual:

• fails to notify the board of any adverse actions taken against his license
• has restrictions placed on or disciplinary action taken against his license in any state or jurisdiction;
• violates any of the requirements of this section; or
• commits any act that constitutes grounds for disciplinary action under the board’s statutes or regulations.

For the purposes of this section, the delivery of behavioral telehealth services by a registrant licensed by another state or jurisdiction to a client residing in this State is deemed to occur in this State, and the registrant consents, as a condition of registration, to the personal and subject matter jurisdiction and disciplinary authority of the board.

Nothing in this section requires or authorizes an individual licensed by this State pursuant to this chapter to obtain a behavioral telehealth registration in order to provide behavioral telehealth services to a client residing in this State.

SOURCE: SC Code Annotated Sec. 40-63-35 . (Accessed Feb. 2024).

For purposes of this chapter, ‘behavioral telehealth’ means the practice of professional counseling, addiction counseling, marriage and family therapy, and licensed psycho‑educational specialty using electronic communications, information technology, or other means between a registrant located outside this State and a client located in this State with or without an intervening practitioner. A behavioral telehealth provider has the duty to practice in a manner consistent with his scope of practice and the prevailing professional standard of practice for a behavioral health care professional who provides in‑person professional counseling, addiction counseling, marriage and family therapy, and licensed psycho‑educational specialist services to clients in this State.

Individuals who hold an active license to provide professional counseling, addiction counseling, marriage and family therapy, and licensed psycho‑educational specialist services in another state or jurisdiction may provide these services using behavioral telehealth to a client located in this State if the individual is registered with the board and provides the services within the applicable scope of practice established by this State.

• be licensed with an active, unencumbered license that is issued by another state, the District of Columbia, or a possession or territory of the United States and that is substantially similar to a license issued by South Carolina to a professional counselor, addiction counselor, marriage and family therapist, or licensed psycho‑educational specialist;

The individual may not register under this subsection if his license to provide professional counseling, addiction counseling, marriage and family therapy, or licensed psycho‑educational specialist services is subject to a pending disciplinary investigation or action, or has been revoked in any state or jurisdiction. An individual registered under this section must notify the board of restrictions placed on his license to practice or any disciplinary action taken or pending against him in any state or jurisdiction. The notification must be provided within five business days after the restriction is placed or disciplinary action is initiated or taken.

The board shall publish on its website a list of all registrants and include, to the extent applicable, each registrant’sname, address, out‑of‑state professional license type with the license number, and South Carolina behavioral telehealth registration number.

Nothing in this section requires or authorizes an individual licensed by this State pursuant to this chapter to obtain a behavioral telehealth registration in order to provide behavioral telehealth services to a client residing in this State.”

SOURCE: SC Code Annotated Sec. 40-75-800 . (Accessed Feb. 2024).

Telemedicine means the practice of medicine using electronic communications, information technology, or other means between a licensee in one location and a patient in another location with or without an intervening practitioner.

SOURCE:   SC Code Annotated Sec. 40-47-20 (52). (Accessed Feb. 2024).

South Carolina law addresses telemedicine under veterinary services, stating, “telemedicine is an audio, video, or data communication of medical information.”

SOURCE:   SC Code Annotated Sec. 40-69-20 (15). (Accessed Feb. 2024).

Member of the Physical Therapy Compact

SOURCE: Compact Map. Physical Therapy Compact. (Accessed Feb. 2024).

Member of the Nurse Licensure Compact

SOURCE: Current NLC States & Status. Nurse Licensure Compact. (Accessed Feb. 2024).

Member of Emergency Medical Services (EMS) Compact

SOURCE: Interstate Commission for EMS Personnel Services, Compact Member States, (Accessed Feb. 2024).

Member of Occupational Therapy Licensure Compact

SOURCE: OT Compact Map. (Accessed Feb. 2024).

Member of Audiology and Speech-Language Pathology Interstate Compact

SOURCE: ASLP-IC Compact Map. (Accessed Feb. 2024).

Member of the Psychology Interjurisdictional Compact (PSYPACT)

SOURCE: PSYPACT Map. (Accessed Feb. 2024).

* See Compact websites for implementation and license issuing status and other related requirements.

Specific tasks may be delegated to a certified medical assistant (CMA) by a physician, physician assistant if authorized to do so in his scope of practice guidelines, or advanced practice registered nurse if authorized to do so in his practice agreement. The scope of practice guidelines for a physician assistant and the practice agreement for an advanced practice registered nurse must address what tasks may be appropriately delegated to a CMA, provided, however, that certain tasks, including performing a clinical decision‑making task by means of telemedicine, must not be delegated to a CMA by a physician assistant or advanced practice registered nurse.

SOURCE:  SC Code Annotated Sec. 40-47-196 . (Accessed Feb. 2024).

A licensee who establishes a physician-patient relationship solely via telemedicine shall adhere to the same standard of care as a licensee employing more traditional in-person medical care and be evaluated according to the standard of care applicable to the licensee’s area of specialty. A licensee shall not establish a physician-patient relationship by telemedicine for the purpose of prescribing medication when an in-person physical examination is necessary for diagnosis.

Schedule II and Schedule III prescriptions are not permitted except for those Schedule II and Schedule III medications specifically authorized by the board, which may include, but not be limited to, Schedule II-nonnarcotic and Schedule III-nonnarcotic medications.

To establish a physician-patient relationship via telemedicine, the provider must:

• Comply with state and federal laws on patient confidentiality
• Adhere to current standards of practice improvement and monitoring of outcomes and provide reports containing such information upon request of the board;
• Provide an appropriate evaluation prior to diagnosing and/or treating the patient, which need not be done in-person if the licensee employs technology sufficient to accurately diagnose and treat the patient in conformity with the applicable standard of care; provided, that evaluations in which a licensee is at a distance from the patient, but a practitioner is able to provide various physical findings the licensee needs to complete an adequate assessment, is permitted; further, provided, that a simple questionnaire without an appropriate evaluation is prohibited;
• Verify the identity and location of the patient and be prepared to inform the patient of the licensee’s name, location and professional credentials;
• Establish a diagnosis through the use of accepted medical practices, which may include patient history, mental status evaluation, physical examination, and appropriate diagnostic and laboratory testing in conformity with the applicable standard of care;
• Ensure availability of follow-up care and maintain a complete medical record that is available to the patient and other treating health care practitioners, to be distributed to other treating health care practitioners only with patient consent and in accordance with applicable law and regulation;
• Prescribe within a practice setting fully in compliance with the law and during an encounter in which threshold information necessary to make an accurate diagnosis has been obtained in a medical history interview conducted by the prescribing licensee. See Code for specific information on controlled substances.
• Maintain a complete record of the patient’s care according to prevailing medical record standards that reflects an appropriate evaluation of the patient’s presenting symptoms; provided that relevant components of the telemedicine interaction be documented as with any other encounter;
• Maintain the patient’s records’ confidentiality and disclose the records to the patient consistent with state and federal law; provided, that licensees practicing telemedicine shall be held to the same standards of professionalism concerning medical records transfer and communication with the primary care provider and medical home as licensees practicing via traditional means; further, provided, that if a patient has a primary care provider and a telemedicine provider for the same ailment, then the primary care provider’s medical record and the telemedicine provider’s record constitute one complete medical record;
• Be licensed to practice in South Carolina provided, however, a licensee need not reside in South Carolina so long as he or she has a valid, current South Carolina medical license; further, provided, that a licensee residing in South Carolina who intends to practice medicine via telemedicine to treat or diagnose patients outside of South Carolina shall comply with other state licensing boards; and
• Discuss with the patient the value of having a primary care medical home and, if the patient requests, provide assistance in identifying available options for a primary care medical home.

A licensee, practitioner, or any other person involved in a telemedicine encounter must be trained in the use of the telemedicine equipment and competent in its operation.

Schedule II and III prescriptions are not permitted except as specifically authorized by the board.

Prescribing abortion-inducing drugs is not permitted; as used in this article “abortion-inducing drug” means a medicine, drug, or any other substance prescribed or dispensed with the intent of terminating the clinically diagnosable pregnancy of a woman, with knowledge that the termination will with reasonable likelihood cause the death of the unborn child.

SOURCE:  SC Code Annotated Sec. 40-47-37. (Accessed Feb. 2024).

Professional Board Standards

South Carolina Board of Examiners in Psychology*

SOURCE: Telehealth Statement, March 11, 2019. (Accessed Feb. 2024).

South Carolina Board of Physical Therapy Examiners*

SOURCE: Advisory Opinion On The Use Of Telehealth, Oct. 28, 2020. (Accessed Feb. 2024).

South Carolina Board of Occupational Therapy*

SOURCE: Advisory Opinion On The Use Of Telehealth, June 12, 2020 (Accessed Feb. 2024).

South Carolina Board of Examiners in Speech-Language Pathology and Audiology*

SOURCE: Policy Regarding Telepractice, 2022. (Accessed Feb. 2024).

* The policies above are not official law or regulation, however are ‘advisory opinions’ or statements released by specific boards in the state on telehealth.

Federally Qualified Health Center (FQHC)

Currently the definition of a visit is a face-to-face encounter between an FQHC patient and a physician, PA, NP, CNM, chiropractor, clinical psychologist or clinical social worker, during which a Medicaid-covered FQHC core service is furnished. The South Carolina Medicaid program does not cover nutrition, health education, social work, or other related ancillary services unless noted in this section. For billing purposes, SCDHHS has deemed a “visit” as an “encounter”. Physicians and practitioners providing services under the FQHC program must meet the regular Medicaid enrollment requirements to provide services to Medicaid patients.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 144 (Feb. 2024) . (Accessed Feb. 2024).

A mental health visit is defined as a face-to-face encounter between the FQHC beneficiary and the Physician, Clinical Psychologist, Clinical Social Worker, APRN, Physician Assistant, and Certified Nurse Midwife or an Allied Professional under the direct supervision of a Physician or APRN for mental health services.

SOURCE: SC Health and Human Svcs. Dept. FQHC Behavioral Health Services Provider Manual (Feb. 2023), p. 14. (Accessed Feb. 2024).

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 215 (Feb. 2024). (Accessed Feb. 2024).

A consultant site means the site at which the provider is located at the time the telehealth service is delivered. The provider performing the medical care must be currently and appropriately licensed in South Carolina. FQHC and RHC providers are eligible to serve as consulting site providers for telehealth services.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 32-33 (Feb. 2024). (Accessed Feb. 2024).

Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) will continue to be eligible for reimbursement for services rendered via telehealth. When billing for any telehealth procedure code, providers must submit claims with a GT modifier. If a code requires any other billing modifiers when submitting claims, the GT modifier should be listed after any other modifiers.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin 23-018. (May 2023). (Accessed Feb. 2024).

FQHCs are covered referring sites – A referring site (also called the patient site) is the location of an eligible Medicaid beneficiary at the time the telehealth service is being furnished . Medicaid beneficiaries are eligible for telehealth services only if they are presented from a referring site located in the SCMSA. Referring site presenters may be required to facilitate the delivery of this service. Referring site presenters should be a person knowledgeable in how the equipment works and able to provide clinical support if needed during a session.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 33 (Feb. 2024). (Accessed Feb. 2024).

The referring site, also known as the originating site, is only eligible to receive a facility fee for telehealth services. Claims must be submitted with an appropriate HCPCS code (telehealth originating site facility fee). If a provider from the referring site performs a separately identifiable service for the beneficiary on the same day as telehealth, 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 reimbursement for a facility fee for the telehealth services when operating as the referring site. Claims must be submitted with the HCPCS code for telehealth referring site facility fee. When serving as the referring site, the RHCs and FQHCs cannot bill the encounter code if these are the only services being rendered.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 215 (Feb. 2023). (Accessed Feb. 2024).

FQHC services are covered when furnished to patients at the center, in a SNF, or at the client’s place of residence. Services provided to hospital patients, including ER services, are not considered FQHC services.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 144 (Feb. 2024). (Accessed Feb. 2024).

Patient Home as Referring Site

SCDHHS will waive referring site restrictions that existed prior to the COVID-19 PHE, which will allow providers to be reimbursed for services delivered via telehealth to Healthy Connections Medicaid members regardless of the members’ location as described in Medicaid bulletin  20-005 . This flexibility applies to the evaluation and management (E/M) Current Procedural Terminology (CPT) codes listed below for services rendered by a physician, nurse practitioner, or physician assistant. This flexibility will be made permanent for evaluation and management encounters that include both audio and visual components.

South Carolina Medicaid will reimburse for live video.

See: SC Medicaid Live Video

G2010 (Remote image submitted by a patient) is listed as reimbursed for FQHCs for established patients.

Generally, however, SC doesn’t appear to cover store-and-forward services.

See: SC Medicaid Store-and-forward

No RPM coverage for FQHCs.

See: SC Medicaid RPM

Services rendered through an FQHC or RHC for certain audio-only CPT codes will be reimbursed.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin 22-005. (May 2023). (Accessed Feb. 2024).

See: SC Medicaid Email, Phone, & Fax

No explicit FQHC reference found.

For general information about prescribing see: SC Professional Requirements Online Prescribing

Telehealth services will continue to be reimbursed as a “bill-above” service and will be paid outside of the established encounter rate. Providers will instead receive the reimbursement rate from the applicable SCDHHS fee schedule.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 215 (Feb. 2024) . (Accessed Feb. 2024).

All medical encounters must be billed using the appropriate encounter code unless otherwise specified. A medical “visit” (encounter) is defined as a face-to-face encounter between a patient and the physician, PA, NP, chiropractor or CNM during which an FQHC core service is provided. FQHC providers will be reimbursed their contracted encounter rate, and are allowed only one medical encounter per day, even if the patient sees more than one professional at the visit or on that day. The use of this code counts toward the ambulatory visit limit for beneficiaries age 21 or older.

All maternal care encounters must be billed with the appropriate encounter code with a TH modifier. FQHC providers will be reimbursed their contracted rate for all maternal services rendered.

SCDHHS allows FQHCs to bill for HIV/AIDS and cancer-related services using the appropriate encounter code, with the P4 modifier.

The FQHC laws established a set of health care services called “FQHC services” for which Medicare and/or Medicaid must cover on a reasonable cost basis when provided by an FQHC. Encounter services are referred to as FQHC core services. Core services are reimbursed using encounter codes.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 143-144, 261-262 (Feb. 2024). (Accessed Feb. 2024).

Only one encounter code is allowed per day, with the exception of the psychiatry and counseling encounter, which can be billed in addition to another encounter on the same day. FQHC services are covered when furnished to patients at the center, in a SNF, or at the client’s place of residence. Services provided to hospital patients, including ER services, are not considered FQHC services.

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.

BlueChoice HealthPlan of South Carolina Expands Access to Telehealth Benefits!

As we continue to monitor the spread of COVID-19, we want to make you aware of expanded telehealth options available to our members. With telehealth, you can consult with a health care provider without leaving your home. This can help minimize the spread of illness.

Telehealth lets you consult with a health care provider by phone or through video chats on your computer, smartphone or other device. The doctor will advise if you should seek in-person medical help or if you can treat your symptoms at home. Doctors can even prescribe medicine through telehealth, if needed.

Telehealth Visits With In-Network Providers 

If you need follow-up care from an in-network provider and would prefer a virtual visit instead of in-person care, you may have the option to arrange telephone or video appointments with the provider. You would pay your normal cost share as you would for an in-person visit. 

• SCtelehealth

South Carolina Telehealth Alliance

• Billing and Reimbursement

Information

The following definitions are based on cms medicare and medicaid services, and also used by many private payers..

Please note : The definitions below are based on pre-COVID policies. Please review the SCTA COVID-19 resource page, the Center for Connected Health Policy (CCHP), SC DHHS for updated information on payers’ telehealth policies during COVID-19.

Telemedicine:

South Carolina definition —“The practice of medicine using electronic communications, information technology, or other means between a licensee in one location and a patient in another location with or without an intervening practitioner. This definitiondoes not, on its face, explicitly require synchronous interactive audio-video communications technology. However, licensees must use technology sufficient to accurately diagnose and treat the patient in conformity with the applicable standard of care.” Former Governor Nikki Haley signed S.1035 into law in June 2016. One of the key features sets standard of care when establishing patients via synchronous communications (video visits).

Originating site, aka referring site: Location of the patient

• Physician or practitioner offices
• Critical access hospitals
• Rural health clinics
• Federally qualified health centers
• Hospital based or CAH-based renal dialysis center
• Skilled nursing facilities
• Community mental health centers
• * Note : Independent renal dialysis facilities are not covered originating sites.
• Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014. Coverage and billing varies by payer. Please check payer policies for guidance.

Distant site, aka consulting site: Location of the distant or consulting provider

Current covered distant providers, varies by payer: Physician Nurse practitioner Physician assistant Nurse midwife Clinical nurse specialist Certified registered nurse anesthetist Clinical psychologist Clinical social worker Registered dietitian

Billing professional fee with the GT modifier:

Distant site providers must submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications systems” (for example, 99201 GT).

The GT modifier is added to the CPT code to alert the insurance company that the service was provided via telehealth. Per CMS, “by coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when you furnished the telehealth service.” CPT and HCPCS code coverage varies by payer. Please check payer policies for guidance.

Health Professional Shortage Area (HPSA),aka rural area:Applies toMedicare coverage only.

Patients must be in an HPSA for services to be covered for telemedicine service.

Health Plan Telehealth Policies Aetna Blue Cross Blue Shield (TeleHealth) Blue Cross Blue Shield (Telemedicine) Humana Medicare SC Medicaid SC Medicaid Rehab (Psych) Select Health Tricare UnitedHealthCare

MEDICARE REIMBURSEMENT Medicare reimburses telemedicine services at the same rate as the comparable-in-person medical service, based on the current Medicare physician fee schedule. As mentioned above, the originating site can charge an additional facility fee and must be rural, accordingto HRSA.

Additional Resources and Information VisitCMS’ Medicare Telehealth for more information.

MEDICAID REIMBURSEMENT

Medicaid will reimburse covered telehealth services as long as the following criteria are met:

Medicaid beneficiaries (patient) are eligible for telemedicine services only if they are presented from a referring or originating site located in the South Carolina Medical Service Area (SCMSA). The referring site presenters may be required to facilitate the delivery of this service. Referring site presenters should be provider knowledgeable in how the equipment works and can provide the clinical support if needed during a session.

Only certain CPT codes are eligible for telemedicine reimbursement.

Medicaid has specific list of CPT codes that are covered under telemedicine services. For more information, see SC Department of Health and Human Services.

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Virtual Specialty & Primary Care FAQs

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