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Clarification of DMAS Requirements Related to the Use of Telemedicine in Providing Medication Assisted Treatment for Opioid Use Disorder

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Bulletin
Effective Date:

To:
All Addiction and Recovery Treatment Services (ARTS) Providers, Prescribers, Managed Care Organizations (MCOs) and Magellan of Virginia Participating in the Virginia Medical Assistance Program
From:
Karen Kimsey, Director DMAS

The goal of the Department of Medical Assistance Services (DMAS) is to ensure individuals with an Opioid Use Disorder (OUD) obtain access to high quality, evidence-based Medication Assisted Treatment (MAT).  MAT includes both the use of the Food and Drug Administration (FDA) approved medications to treat OUD combined with psychosocial and other interventions.

Available here: https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Diso…

This bulletin clarifies the use of telemedicine in the service delivery of MAT for prescribing controlled substances for the treatment of addiction, including buprenorphine and buprenorphine/naloxone as well as psychotherapy and substance use disorder (SUD) counseling. 

DMAS Telemedicine Definitions

  • DMAS defines telemedicine as a service delivery model that uses real-time, interactive telecommunications equipment to deliver covered medical, physical and behavioral health services for the purposes of diagnosis and treatment.  
  • For purposes of this guidance, a qualified provider is defined as a DMAS-enrolled, Virginialicensed practitioner acting in the usual course of their professional practice, and in accordance with state law. A qualified prescribing provider is defined as a DMAS-enrolled, DEAregistered, Virginia-licensed practitioner acting in the usual course of their professional practice, and in accordance with state law prescribes controlled substances. 
  • A telepresenter is staff located at the originating site and is available to the member to ensure the proper set up and use of the technology involved.
  • A credentialed addiction treatment professional includes the following and must act within the scope of their practice: an addiction-credentialed physician or physician with experience in addiction medicine; licensed psychiatrist; licensed clinical psychologist; licensed clinical social worker; licensed professional counselor; licensed psychiatric clinical nurse specialist; licensed psychiatric nurse practitioner; licensed marriage and family therapist; licensed substance abuse treatment practitioner; or "Residents" under supervision of a licensed professional counselor, licensed marriage and family therapist or licensed substance abuse treatment practitioner approved by the Virginia Board of Counseling; "Residents in psychology" under supervision of a licensed clinical psychologist approved by the Virginia Board of Psychology; and "Supervisees in social work" under the supervision of a licensed clinical social worker approved by the Virginia Board of Social Work. 
  • An originating site is the location of the individual receiving the covered service at the time the service is rendered.
  • An originating site facility is the DMAS-enrolled facility provider for purposes of billing an originating site facility fee.
  • The distant site is the location of the qualified prescribing provider rendering the covered service at the time the service is rendered. 
  • The distant site billing provider is the DMAS-enrolled facility for purposes of billing for the covered service.

Ryan Haight Act of 2008

Under the Ryan Haight Act of 2008, general requirements are that the prescribing practitioner shall have conducted at least one in-person medical evaluation of the patient before prescribing a controlled substance including buprenorphine and buprenorphine/naloxone for treatment of addiction.  However the Act provides an exception to this requirement.  The Drug Enforcement Agency (DEA) registered practitioner is exempt from this requirement if he/she is engaged in the practice of telemedicine and is acting in accordance with the requirements of 21 U.S.C. §802.  The requirements are that the patient is treated by a practitioner and physically located within a DEAregistered facility, or treated by, and in the physical presence of, a DEA-registered practitioner.

Register as a DEA-Registered Practitioner

A practitioner may apply for a DEA registration number through the United States Drug Enforcement Administration which allows the practitioner to write prescriptions for controlled substances. To apply for a DEA registration as a practitioner, please visit: https://www.deadiversion.usdoj.gov/drugreg/process.htm.

Register as a DEA-Registered Facility

Facilities may also apply for DEA-Registration.  Providers must first apply for a controlled substances registration (CSR) from the Virginia Board of Pharmacy.  The CSR application is located: http://www.dhp.virginia.gov/pharmacy/pharmacy_forms.htm#csr.

Once the provider has been registered as a CSR with the Virginia Board of Pharmacy, the provider shall then register with the DEA as a DEA registered facility.  The DEA Registration is located:

https://www.deadiversion.usdoj.gov/drugreg/reg_apps/224/224_instruct.htm 

Apply for a Practitioner Waiver to Prescribe or Dispense Buprenorphine

To apply for a practitioner waiver to prescribe or dispense buprenorphine medications for treatment of OUD, under the Drug Addiction Treatment Act of 2000 (DATA 2000), a practitioner must notify the Substance Abuse Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) of their intent to practice this form of MAT. The notification of intent must be submitted to CSAT before the initial dispensing or prescribing of opioid treatment.  Eligible physicians are required to complete an eight-hour training to qualify for a waiver to prescribe and dispense buprenorphine. Eligible nurse practitioners and physician assistants must obtain no fewer than 24 hours of initial training including both the eight-hour DATA-waiver course for treatment of opioid use disorder, designed by national experts, that physicians currently take, and the additional 16-hour course offered for free by SAMHSA through the              Providers          Clinical              Support            System.                           More   information     may      be         found   at: https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiv….  

DMAS Requirements for Originating and Remote Sites Providing MAT

Prescribing Via Telemedicine

Prescribing controlled substances for the treatment of addiction delivered via telemedicine must include a qualified provider and a telepresenter located at the originating site, as well as a qualified prescribing provider located at the remote site.  Remote site physicians may be physically located outside of Virginia but shall be located within the continental United States. Out-of-state physicians must also be licensed in the state where they are physically located and must also be enrolled with Virginia DMAS.  If the Medicaid member receiving services is enrolled in one of DMAS’ Managed Care Organizations (MCOs), the qualified provider and qualified prescribing provider must be enrolled with that MCO, in addition to being enrolled with DMAS.  

The originating site shall define roles of the telepresenter or other qualified staff that include collecting vital signs, implementing the Clinical Opiate Withdrawal Scale (COWS) assessment, communicating with the member and remote qualified prescriber, setting up equipment and making video connections for each scheduled session, responding to emergencies, etc.  The telepresenter or other qualified staff shall work with the member to address any medical or behavior issues involved in the process, and also ensure the proper use of the technology involved.  Staff at the originating site shall designate an emergency contact where the member is located if there are clinical or safety concerns.  There shall be procedures in place in the event an emergency hospitalization becomes necessary.  The remote prescriber uses the transmitted information to deliver physical and/or behavioral health services from the remote site for the purposes of diagnosis and treatment of the member.  

Psychotherapy and SUD Counseling Via Telemedicine

Psychotherapy and SUD counseling may also be provided via telemedicine by a qualified provider who is a credentialed addiction treatment professional as defined in this memorandum and DMAS ARTS Provider Manual. If the individual receiving services is enrolled in one of DMAS’ MCOs, the qualified provider must be enrolled with that MCO, in addition to being enrolled with DMAS.  The originating site must have the telepresenter or other qualified staff available to the member(s) to help set up equipment, making video connections, responding to emergencies, etc.  The remote qualified provider shall follow suggested practices for providing psychotherapy and SUD counseling as defined by the Substance Abuse Mental Health Services Administration (SAMHSA):              https://www.integration.samhsa.gov/operations-administration/telebehavi….  The American Psychiatric Association has posted guidelines on best practices for providing services through telemedicine:  https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/a…  

Individuals must be given a choice to receive MAT services either in-person or via telemedicine, and consent for the use of telemedicine must be documented in the participant’s medical record.  All providers shall follow the DMAS requirements for coverage of telemedicine as documented in the September XX, 2019 memo entitled, “2019 Update Regarding DMAS Coverage of Telemedicine and Telehealth.”

Billing Medicaid for Telemedicine Services

 

DMAS covers telemedicine where the following elements are met:

  • The DMAS qualified covered service provider is located at an approved remote site.
  • The remote qualified provider is delivering medically necessary services to a Medicaid member.
  • The Member is located at an approved originating site with the Medicaid enrolled telepresenter. 
  • The originating site provider cannot bill an originating site fee unless the Member is assisted by a Medicaid enrolled telepresenter at the originating site. 

 

When these elements are present, the qualified providers at the remote site may bill for services provided to the member as well as the qualified originating site may bill for the originating site fee.  Telemedicine uses the same billing codes as the comparable face-to-face services, with the addition of the telemedicine modifier code.  Audio only telephone calls, e-mail, facsimile transmissions and similar electronic measures are not considered part of the telemedicine or telehealth coverage and should not be to be billed to DMAS or its subcontractors.

Billing Codes for Medication Assisted Treatment Services 

CPT Code

 Description

99201-99205

GT or GQ modifier

 

Initial Evaluation and Management Visit

 

99211-99215

GT or GQ modifier

 

Established Evaluation and Management Visit

 

Q3014

 Telemedicine Facility Fee – Originating site only

90832-90853

 Psychotherapy – Individual, family and group.

Fee-for-services rates are posted online at: http://www.dmas.virginia.gov/#/searchcptcodes.  When billing for MAT services delivered via telemedicine, the “GT” (via interactive audio and video telecommunications system) modifier is used.

The originating site facility, who is enrolled with the Medicaid MCOs or Magellan of Virginia and affiliated with the office or other location where the Medicaid member is located for the telemedicine encounter, must use the procedure code Q3014 (telemedicine facility fee) with the GT modifier entered on the claim. The only procedure code originating sites may bill is Q3014. The originating site provider or telepresenter must attend the encounter with the member.

Preferred Office-Based Opioid Treatment (OBOT) Model

DMAS will update the Addiction and Recovery Treatment Services (ARTS) Opioid Treatment Services Manual Supplement to address policies about providing services via telemedicine in the Preferred OBOT model of care.  DMAS will include any additional requirements in the policy update for Preferred OBOT providers in the delivery of services via telemedicine.  

Relevant State and Federal Policies

https://www.deadiversion.usdoj.gov/mtgs/pract_awareness/resources/Telem… f#search=telemedicine 

  • Informational documents from DEA regarding DATA 2000 Waivers:

https://www.deadiversion.usdoj.gov/pubs/docs/index.html 

https://www.dhp.virginia.gov/medicine/guidelines/85-12.pdf

  • Board of Pharmacy Requirements for Teleprescribing - 18VAC110-20-690(F) Controlled substance registration for naloxone and teleprescribing - Effective 5/8/17 to 5/9/19 Image removed.

Medicaid Expansion

New adult coverage begins January 1, 2019.  Providers will use the same web portal and enrollment verification processes in place today to verify Medicaid expansion coverage.  In ARS, individuals eligible in the Medicaid expansion covered group will be shown as “MEDICAID EXP.”  If the individual is enrolled in managed care, the “MEDICAID EXP” segment will be shown as well as the managed care segment, “MED4” (Medallion 4.0), or “CCCP” (CCC Plus).  Additional Medicaid expansion resources for providers can be found on the DMAS Medicaid Expansion webpage at:  http://www.dmas.virginia.gov/#/medex.  

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated

Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

www.virginiamedicaid.dmas.virginia.gov

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996

KEPRO

Service authorization information for fee-forservice members.

https://dmas.kepro.com/

 

Managed Care Programs

Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), and Program of All-Inclusive Care for the Elderly (PACE).  In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider.  The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Medallion 4.0

http://www.dmas.virginia.gov/#/med4

CCC Plus

http://www.dmas.virginia.gov/#/cccplus

PACE

http://www.dmas.virginia.gov/#/longtermprograms

Magellan Behavioral Health

Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members.

www.MagellanHealth.com/Provider

For credentialing and behavioral health service information, visit: www.magellanofvirginia.com, email:

VAProviderQuestions@MagellanHealth.com,or call: 1-800-424-4046

 

 

Provider HELPLINE

Monday–Friday 8:00 a.m.-5:00 p.m.  For provider use only, have Medicaid Provider ID Number available.

1-804-786-6273

1-800-552-8627