Telemedicine/Telehealth Facilitation of Mental Health Rehabilitation (MHR) Services during the COVID-19 Declared Emergency (IB 20-4 revised 5.12.23)

Date: 05/12/23

Louisiana Healthcare Connections is sharing with providers a revision made to telemedicine/telehealth facilitation of MHR services during the COVID-19 emergency (IB 20-4) on May 12, 2023. The most significant change is that LDH is requesting approval by CMS for an effective date of May 1, 2023 to help provide uninterrupted telehealth CPST services to Louisiana residents.

The complete informational bulletin is below. Addition is in italic.

The Louisiana Department of Health (LDH) acknowledges the need for the continued facilitation of MHR services during the COVID-19 declared emergency. As in-person intervention is the only approved method for providing MHR services under normal circumstances, an allowance to deliver these services via an alternate method required approval from the Centers for Medicare and Medicaid Services (CMS). LDH is issuing approval effective for dates of service beginning on or after March 20, 2020, which will remain in effect until rescinded by LDH.

The Biden Administration announced the public health emergency is set to expire on May 11, 2023. Effective May 12, 2023, mental health rehabilitation services (see list of services under General Considerations) shall be provided through an in-person delivery method in accordance with federal requirements and the Medicaid Behavioral Health Services Provider Manual. Mental health rehabilitation assessments conducted by a licensed mental health professional (LMHP) may continue to be provided through telehealth using a secure telecommunications system which is compliant with HIPAA requirements; assessments conducted by an LMHP through telehealth should include synchronous, interactive, real-time electronic communication comprising both audio and visual elements, unless clinically appropriate and based on documented member consent effective May 12, 2023.

The Medicaid Behavioral Health Services Provider Manual can be found at the following link: https://www.lamedicaid.com/provweb1/providermanuals/BHS_main.htm.

LDH is seeking continued CMS approval of telehealth Community Psychiatric Support and Treatment (CPST) services. The telehealth facilitation of CPST services will technically end as of May 12, 2023, as the telehealth allowance was temporary due to the COVID-19 pandemic. To maintain continued telehealth CPST services, LDH has revised its State Plan Amendment (SPA), adding telehealth as an allowable mode of delivery for CPST. In the SPA submission, LDH has requested an effective date of May 1, 2023, with the hopes of providing uninterrupted telehealth CPST services to Louisiana residents. LDH expects CMS approval by mid-to-late June 2023.

General Considerations

Telemedicine/telehealth does not exempt providers from any of the service requirements or record keeping as set forth in the Medicaid Behavioral Health Services Provider Manual (PDF). Additional record keeping is mandated for use during the COVID-19 declared emergency as described further in this bulletin. LDH will not waive licensure or accreditation requirements for agencies providing MHR services. Providers must meet agency and staff qualifications and requirements for delivering MHR services, as established in the Medicaid Behavioral Health Services Provider Manual. Licensed mental health practitioners providing services in MHR agencies must also follow rules and regulations established by their respective professional licensing boards. While program requirements for the number or percentage of face-to-face contacts for MHR services may be met with the use of telehealth, these temporary measures still require adherence to other requirements that apply to the service delivered, as they would when delivered in-person.

Services must be medically necessary to promote the maximum reduction of symptoms and restoration to both child and adult recipients, as determined by a physician or a fully licensed mental health professional (LMHP). MHR services include the following Medicaid reimbursable services for all levels of staffing (licensed and non-licensed staff):

Community Psychiatric Support and Treatment (CPST).
Psychosocial Rehabilitation (PSR).
Crisis Intervention (CI).
Assertive Community Treatment (ACT).
Functional Family Therapy (FFT) and Functional Family Therapy-Child Welfare (FFT-CW);
Homebuilders®.
Multi-Systemic Therapy (MST).

When using telemedicine/telehealth, please follow these guidelines:

Confidentiality still applies for services delivered through telemedicine/telehealth. The session must not be recorded without consent from the recipient or authorized representative.
Develop a back-up plan (e.g., phone number where recipient can be reached) to restart the session or to reschedule it, in the event of technical problems.
Develop a safety plan that includes at least one emergency contact and the closest ER location, in the event of a crisis.
Verify recipient’s identity, if needed.
Providers need the consent of the recipient and the recipient’s parent or legal guardian (and their contact information) prior to initiating a telemedicine/telehealth service with the recipient if the recipient is 18 years old or under.
The recipient must be informed of all persons who are present and the role of each person.
Recipients may refuse services delivered through telehealth or request that services be delivered in-person. In these cases, the provider must provide an in-person service or refer to an equally qualified provider.
It is important for the provider and the recipient to be in a quiet, private space that is free of distractions during the session.

Providers of evidence-based practice (EBP) services should consult national training organizations (such as FFT, LLC; MST, Inc.; and IFD) on guidance for adapting the EBP model for use in a telemedicine/telehealth situation.

Communication Requirements

During this COVID-19 declared emergency, LDH is issuing approval for the delivery of MHR services via telemedicine/telehealth communications. Providers offering services via telemedicine/telehealth must use a secure, HIPAA-compliant platform, if available. If not available during the public health emergency, providers may use everyday communication technologies, including audio-only delivery of telemedicine/telehealth services (e.g. telephone) or use of videoconferencing (e.g. Skype, FaceTime) programs that have reasonable security and privacy measures, with each recipient’s consent. NOTE: Effective May 12, 2023, assessments that are conducted by an LMHP using telehealth must include a secure telecommunication system which is compliant with HIPAA requirements. Facebook Live, Twitch, TikTok, and similar video communication applications are public facing and must not be used for telemedicine/telehealth services. Audio-only delivery is allowed only in situations where an audio/video system is not available or not feasible, and when provided in a manner that is consistent with the applicable requirements of HIPAA. Effective May 12, 2023, MHR assessments provided through telehealth should include synchronous, interactive, real-time electronic communication comprising both audio and visual elements, unless clinically appropriate and based on documented member consent. Although a combined audio/video system is preferred, LDH is allowing MHR providers to practice telemedicine/telehealth through telephonic communications when appropriate. Texting and emails are not approved forms of telemedicine/telehealth. At minimum, there must be an audio connection. Providers must adhere to all telemedicine/telehealth-related requirements of their professional licensing board.

There is currently no formal limitation on the originating site (i.e., where the recipient is located) and this can include, but is not limited to, a healthcare facility, a school or the recipient’s home. Regardless of the originating site, providers must maintain adequate medical documentation to support reimbursement of the visit.

Assessments and Re-evaluations

LDH is issuing approval to utilize telemedicine/telehealth for conducting MHR assessments by LMHPs, when clinically appropriate and based on member preferences. Effective May 12, 2023 MHR assessments provided through telehealth should include synchronous, interactive, realtime electronic communication comprising both audio and visual elements, unless clinically appropriate and based on documented member consent.

Documentation

Informed Consent Form for Telemedicine/Telehealth: Providers must have informed consent to deliver telemedicine/telehealth services. The consent form must include the following:

A recipient’s authorization to receive telemedicine/telehealth services after a discussion of the following elements:

The rationale for using telemedicine/telehealth in place of in-person services.
The risks and benefits of the telemedicine/telehealth, including privacyrelated risks.
Possible treatment alternatives and those risks and benefits.
The risks and benefits of no treatment.

Progress Notes

Providers should record all aspects of telephonic, telehealth and/or face-to-face encounters in the recipient’s clinical record, including, but not limited to the following:

Name of recipient and any others present/participating.
Dates and time of service contacts (include both start and stop times).
Content of each delivered service, including the reason for the contact describing the goals/objectives addressed during the service, specific intervention(s), progress made toward functional and clinical improvement.
Specific intervention(s) provided, including any units of service provided.
Service location for each intervention. It must be documented that the service is being conducted via telemedicine/telehealth. For use of an audio-only system, the rationale for employing an audio-only system must be documented in the clinical record.
Crisis plan, including any changes related to COVID-19 risks.
Any new treatment plan interventions, goals and objectives related to treatment and/or COVID-19-related risks.
Any referral of recipients to healthcare providers for further screening, testing or treatment of COVID-19 symptoms or history.
Document a back-up plan (e.g., phone number where recipient can be reached) to restart the session or to reschedule it, in the event of technical problems.
Document a safety plan that includes at least one emergency contact and the closest ER location, in the event of a crisis.
Document verification of the recipient’s identity, if needed.
Document the recipient is informed of all persons who are present and the role of each person.
Document if recipient refuses services delivered through telehealth.
Document the consent of the recipient and the recipient’s parent or legal guardian (and their contact information) prior to initiating a telemedicine/telehealth service with the recipient if the recipient is 18 years old or under.
Name and functional title of person making record entry and providing service.

Documents Requiring Recipient Signature

Providers must verbally review and discuss the documents requiring recipient signature (e.g. treatment plan, member choice form, informed consent form) with the recipient/recipient’s family during the telemedicine/telehealth visit. The provider will be required to indicate the recipient/recipient’s family participation, if appropriate, and agreement. The provider shall document as such on the signature line and in the corresponding progress note (if applicable) that includes the date and time of the meeting. When possible (i.e. at the next in person treatment planning meeting), providers should have the recipients sign all documents that had verbal agreements.

Staff Supervision

Staff supervision must continue to follow published guidelines in the Medicaid Behavioral Health Services Provider Manual. Supervision may follow the same guidelines as service delivery with regard to the manner of communication. Supervision must use a secure, HIPAAcompliant platform, if available. If not available during the public health emergency, providers may use everyday communication technologies, including audio-only supervision (e.g. telephone) and use of videoconferencing (e.g. Skype, FaceTime) programs that have reasonable security measures. NOTE: Effective May 12, 2023, supervision must be provided using a secure HIPAA-compliant platform. Facebook Live, Twitch, TikTok, and similar video communication applications are public facing and must not be used for supervision. Audio-only delivery is allowed only in situations where an audio/video system is not available or not feasible, and when provided in a manner that is consistent with the applicable requirements of HIPAA. Texting and emails are not approved forms of supervision. At minimum, there must be an audio connection. These measures still require adherence to other requirements that apply to staff supervision.

Authorizations

An existing prior authorization does not need an addendum to be eligible for telemedicine/telehealth delivery. Requirements for reimbursement are otherwise unchanged from the Medicaid Behavioral Health Services Provider Manual.

From March 20, 2020 through April 30, 2021, LDH issued approval for MCOs to extend existing prior authorizations (PA) for MHR services that reach the end of the authorization period during the COVID-19 declared emergency. Beginning May 1, 2021 PAs will return to each MCO’s standard operating procedure. MCOs may request documentation from providers to be aware of continuation of services, any needs for continued service continuity, or perhaps even needs to expand service coordination. New requests should follow standard processes in place with the recipient’s MCO.

Billing and Reimbursement

For these services, the providers must bill the procedure code (HCPCS codes) with modifier “95,” as well as Place of Service “02” (other than home) or 10 (home) when delivering the service through telemedicine/telehealth. Reimbursement for visits delivered via telemedicine/telehealth is similar to in-person visits, subject to any terms and conditions in provider contracts with Medicaid managed care entities. Reimbursement will be the same as the MHR community in-person rate unless otherwise specified in the Specialized Behavioral Health Fee Schedule or the Medicaid Behavioral Health Services Provider Manual.

The new Place of Service code 10, “telehealth provided in patient’s home,” can be used effective date of service January 1, 2022 going forward. Providers should contact their contracted MCO for information that may affect billing procedures and reimbursement rates.

Claims processing systems will be updated by March 27, 2020. Before that date, providers should continue to submit claims and they will be recycled with no action needed by the provider. A list of relevant procedure codes can be found on the Specialized Behavioral Health Fee Schedule. Providers must indicate place of service “02” (other than home) or 10 (home) and must append modifier “95.”

Resources

Providers may find more information about the coronavirus (COVID-19), including tips and resources for healthcare providers, by visiting http://ldh.la.gov/Coronavirus/. Specific information for providers is located here: http://ldh.la.gov/index.cfm/page/3880.

Providers interested in learning more about telemedicine/telehealth can find a toolkit here. There are 14 videos on Practice and Clinical Issues. These focus on the efficacy of telehealth and tips on making clinical interventions successful and would be helpful for agency owners, professional and non-professional staff. They are all very short and include a written summary of video content.