Telehealth Regulation and Reimbursement



IPA is compiling a "members only" page with up-to-date Telehealth Regulation and Reimbursement information. The content has been vetted by our Executive Director, Dick Rhoad, and is shared with you as we receive it. 

There are numerous updates supporting expanded use of Telepsychology for IPA members. 
 
 
TELEPSYCHOLOGY UPDATES APRIL 9, 2020
The following references are updates for:
  • Indiana
  • Michigan
  • Illinois
  • Kentucky
  • Ohio
  • Medicare-Medicaid
Let us know if you have any questions. 
INDIANA
Executive Order 20-05 - https://www.in.gov/gov/files/EO_20-05.pdf
10. Public Licensing Agency (PLA)
A. Suspension of the requirement that a health care provider hold an Indiana license if he or she: (1) has an equivalent license from another State, and (2) is not suspended or barred from practice in that State or any State.
B. Mental health professionals are permitted to practice via telemedicine.
Executive Order 20-13 - https://www.in.gov/gov/files/Executive%20Order%2020-13%20Medical%20Surge.pdf
5. Telemedicine
a. Unless otherwise specified, the prohibition against audio-only telemedicine as set forth in Ind. Code . . . is suspended for health care providers who are permitted to practice telemedicine and reimbursement will be allowed under Ind. Code . . .
d. As authorized in Executive Order 20-5, FSSA shall suspend Telehealth restrictions for expanded telemedicine services rendered under the authority of this Order and any other Executive Order issued for this public health emergency.
e. IDOI (Indiana Department of Insurance) shall request health insurers to provide coverage for expanded telemedicine services rendered under the authority of this Order and any other Executive Order issued for this public health emergency.
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MICHIGAN
Executive Order 2020-30 - https://www.michigan.gov/whitmer/0,9309,7-387-90499_90705-523481--,00.html
Temporary relief from certain restrictions and requirements governing the provision of medical services
3. Any and all provisions in Article 15 of the Public Health Code are temporarily suspended, in whole or part, to the extent necessary to allow health care professionals licensed and in good standing in any state or territory in the United States to practice in Michigan without criminal, civil, or administrative penalty related to lack of licensure. A license that has been suspended or revoked is not considered a license in good standing, and a licensee with pending disciplinary action is not considered to have a license in good standing. Any license that is subject to a limitation in another state is subject to the same limitation in this state.
MSA 20-13  file:///C:/Users/IPA/Documents/1-2020/Communications/Coronavirus%202020/Federal/MI%20Telemedicine%2003.20.20.pdf
General Telemedicine Policy Expansion
During this period . . . , all codes on the telemedicine database ( which encompasses primary care, behavioral health, etc.) will be allowed for the service delivery method telephonic (audio) only.
 
MSA 20-12 https://www.michigan.gov/documents/mdhhs/MSA_20-12_684250_7.pdf
Relaxing Face to Face Requirement
During this time, providers may use telephonic, telemedicine and video technology commonly available on smart phones for program functions that require in-person communication so long as they meet Health Insurance Portability and Accountability Act (HIPAA) compliance standards and the beneficiary or legal representative consents to the method.
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ILLINOIS
Executive Order Telehealth 03.19.20 https://www2.illinois.gov/Pages/Executive-Orders/ExecutiveOrder2020-09.aspx
Section 1. Telehealth Services shall be defined to include the provision of health care, psychiatry, mental health treatment, substance use disorder treatment, and related services to a patient, regardless of their location, through electronic or telephonic methods, such as telephone (landline or cellular), video technology commonly available on smart phones and other devices such as FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, and videoconferencing, as well as any method within the meaning of telehealth services
Section 2. . . . all health insurance issuers regulated by the Department of Insurance are hereby required to cover the costs of all Telehealth . . .
Section 3.  . . . health insurance issuers shall not impose upon Telehealth Services utilization review requirements that are unnecessary, duplicative, or unwarranted, nor impose any treatment limitations that are more stringent than the requirements applicable to the same health care service when rendered in-person.
Section 4. Health insurance issuers shall not impose any cost-sharing (copayments, deductibles, or coinsurance) for Telehealth Services
Illinois Department of Financial and Professional Regulation 3-30-20
 
Guidance for Out-of-State Physicians using Telehealth Services in Illinois
https://www.idfpr.com/News/2020/2020%2003%2030%20Guidance%20for%20Healthcare%20Providers%20using%20Telehealth%20Services%20in%20Illinois.PDF
The Department interprets Executive Order 2020-9 to permit an out-of-state health care provider not licensed in Illinois to continue 
 where there is a previously established provider/patient relationship. The Department deems such a provider to be "authorized to practice in the State of Illinois" pursuant to Section 5 of the Executive Order without further need to obtain licensure in Illinois.
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KENTUCKY
Kentucky Board of Examiners of Psychology http://psy.ky.gov/Documents/PSY%20COVID19%20Memorandum.pdf
1. Suspension of applications for licensure:  Applications for licensure under multiple statutes and regulations, including . . . 201 KAR 26:185, . . ., any and all deadlines for completion or acceptance of applications shall be suspended until ninety (90) days after the state of emergency is lifted.
(Kentucky Statute 201 KAR 26:185. = Details requirements for granting licensure as a psychologist to an applicant licensed in another state.)
 
3. Telehealth: Telehealth services are licensed services provided by electronic means, as opposed to in-person, face-to-face contact. KRS 319.140 provides for use of telehealth as a means of provision of psychological services in Kentucky. . . Until the state of emergency is lifted, a treating psychologist or psychological associate providing or facilitating the use of telehealth services  . . . may do so to meet the mandates of social distancing, including any practitioners who are under a requirement for supervision . . .
 
Kentucky Department of Insurance http://insurance.ky.gov/ppc/Documents/TelehealthRemoteCommunicationsGuidance.pdf
 
The Kentucky Department of Insurance . . . waives the requirements of KRS 304.17A-005(47)(c) pursuant to federal guidance issued by the Office for Civil Rights and the Department for Health and Human Services, which can be located at https://www.hhs.gov/hipaa/for-professionals/specialtopics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.
 
The Department will not impose penalties for noncompliance . . . in connection with the good faith provision of telehealth using such non-public facing audio or video communication products. . . . insurers cannot require that the patient have a prior relationship with the provider in order to have services delivered through telehealth, if the provider determines that telehealth would be medically appropriate.
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OHIO
 
Ohio Board of Psychology https://psychology.ohio.gov/Portals/0/MARCH%2020%20PSYCH%20BOARD%20COVID-19%20ALERT.pdf
 
Temporary License Application is required in Ohio
Amended requirements and permissions for temporary practice via telecommunications:
 1) Permission to practice eligibility is extended to all valid independent psychologist licenses at the doctoral and masters level. Previously, a doctoral degree was required.  
2) The length of authority was extended from 30 practice days to 90 practice days. 
3) At the psychologist's discretion, 90 practice days may be extended to supervisees with clients living in Ohio. Supervisees must practice psychology under supervision of the authorized psychologist in their home state.
4) Academic transcript is waived.
5) The $150 application fee remains in place until further notice. 
 
Application website ishttps://elicense.ohio.gov/OH_HomePage
 
Expanded Access to Telehealth https://coronavirus.ohio.gov/wps/portal/gov/covid-19/checklists/english-checklists/Expanded-Telehealth-Services-COVID-19-Checklist
 
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CMS MEDICARE and MEDICAID
 
CMS - Medicare and Medicaid 
 (1) Updated telehealth billing guidance,
 (2) Announced telephone (audio only) is now available, and
 (3) Reimburses for Neuropsychological Testing.
 
APA has published those recent updates:
April 3, 2020 CMS grants access to new codes for psychologists to use for services delivered via telephones without video. New phone-only billing codes
 
April 6, 2020  CMS offers new instructions on place of service billing for telehealth.
Medicare telehealth billing update
 
April 8, 2020 Billing and other guidance for psychologists who provide psychological and neuropsychological testing services. Neuropsychological and psychological testing during COVID-19




March 31, 2020 - We have favorable updates

All telehealth services are becoming reimbursed by payers.
 
1.   INDIANA EXECUTIVE ORDERS BY THE GOVERNOR
The Governor has signed executive Orders supporting Telehealth in all methods.
Order #20-05
March 19, 2020
10. B. Mental health professionals are permitted to practice via telemedicine.
Order #20-13
March 30, 2020
5.e. IDOI (Indiana Department of Insurance) shall request health insurers to provide coverage for expanded telemedicine service rendered under the authority of this order and any other Executive Order issued for this public health emergency.

2.   CMS SUPPORTS TELEHEALTH
CMS has already announced both Medicare and Medicaid patients are eligible for Telehealth services. In addition, there are no location limitations, so both the provider and patient may be in their office or in their homes. Also, there are no state boundary limits patient and provider may be located in different states if the provider is appropriately licensed.

3.   PRIVATE PAYERS NOW ON BOARD
Payers in Indiana are now accepting Telehealth services video and audio. Each payer may have unique billing requirements, so please confirm the correct coding with each of them.
Some examples are:
ANTHEM / BLUE CROSS BLUE SHIELD
https://providernews.anthem.com/indiana/article/information-from-anthem-for-care-providers-about-covid-19-6
UNITED HEALTHCARE
https://www.uhc.com/health-and-wellness/health-topics/covid-19
Aetna
https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/bh-televideo-service-codes-covid-19.pdf
 
 SPECIFIC PAYER EXAMPLE DETAILS FOLLOW. 
        Please check the website of other payers for their specific directions.
 
ANTHEM / BLUE CROSS BLUE SHIELD
 
Information from Anthem for Care Providers about COVID-19
(Updated March 31, 2020)

https://providernews.anthem.com/indiana/article/information-from-anthem-for-care-providers-about-covid-19-6

Virtual, telehealth and telephonic care
What services are appropriate to provide via telehealth?

Anthem covers telehealth (i.e., video + audio) services for providers who have access to those platforms/capabilities today. Effective March 17, 2020, Anthems affiliated health plans will waive member cost share for telehealth (video + audio) visits, including visits for mental health or substance abuse disorders, for our fully-insured employer plans, individual plans, Medicare plans and Medicaid plans where permissible for 90 days. Cost sharing will be waived for members using Anthems telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

Will Anthem cover telephone-only services in addition to telehealth via video + audio?
Anthem does not cover telephone-only services today (with limited state exceptions) but we are providing this coverage for 90 days effective March 19, 2020, to reflect the concerns we have heard from providers about the need to support continuity of care for Plan members during extended periods of social distancing. Anthem will cover telephone-only medical and behavioral health services from in-network providers and out-of-network providers when required by state law. Anthem will waive associated cost shares for in-network providers only except where a broader waiver is required by law. Exceptions include chiropractic services, physical, occupational, and speech therapies. These services require face-to-face interaction and therefore are not appropriate for telephone-only consultations. Self-insured plan sponsors may opt out of this program.

Telehealth (video + audio)
For 90 days effective March 17, 2020, Anthems affiliated health plans will waive member cost shares for telehealth visits, including visits for mental health or substance use disorders, for our fully-insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible. Cost sharing will be waived for members using Anthems authorized telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

Telephonic-only care
For 90 days effective March 19, 2020, Anthems affiliated health plans will cover telephonic only visits with in-network providers. Out-of-network coverage will be provided where required. This includes covered visits for mental health or substance use disorders and medical services, for our fully insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible. Cost shares will be waived for in-network providers only.

What codes would be appropriate to consider for mental health outpatient and substance abuse outpatient services via telephonic audio-only visits?
For 90 days effective March 19, 2020, Anthem would recognize audio-only time based codes, (99441, 98966, 99442, 98967, 99334, 98968).  These codes do not need a place of service (POS) 02 or modifier 95 or GT.
 
In addition, Anthem would recognize telephonic-only services for diagnostic evaluation (90791-90792), psychotherapy (90832-90838, 90839-90840, 90845-90847), and medication management (90863) with place of service (POS) 02 and modifier 95 or GT. For Medicare Advantage business, please report these telephonic-only services with place of service 02 only.
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UNITED HEALTHCARE
 
https://www.uhc.com/health-and-wellness/health-topics/covid-19

Access to telehealth
Telehealth gives you access to health care providers from the comfort of your home through digital audio-visual technologies, such as FaceTime, Skype, Zoom or dedicated telehealth applications. We expanded access to telehealth to help you stay in your home and reduce exposure to the virus.
24/7 Virtual Visits through designated telehealth providers: These visits are ideal for urgent care. Our preferred telehealth partners include Teledoc, American Well, Doctor On Demand and other partners.

Medicare Advantage and Medicaid members can continue to access their existing telehealth benefit offered through one of our preferred partners without cost-sharing. For members with a telehealth visit through their employer-sponsored plan, cost-sharing for members will be waived until June 18, 2020.
Talk to your health care provider from home: Eligible health care providers can provide a telehealth visit for many of your urgent and non-urgent health care needs. This way, you can stay at home while still receiving the care you need.

Starting March 31, 2020 until June 18, 2020, we are waiving cost-sharing for in-network telehealth visits for Medicare Advantage, Medicaid and fully-insured Individual and Group health plans, with opt-in available for self-funded employers. Telehealth visits may include:
  • Urgent and routine medical care: Providers can use both interactive audio/video and audio-only.
  • Outpatient behavioral care: Providers can use both interactive audio/video and audio-only.
  • Physical, occupational and speech therapies: Providers must use interactive audio/video technology.

    Cost-sharing will be waived for in-network telehealth visits. Out-of-network and cost-sharing will apply, if applicable. Out-of-network telehealth services will be covered in accordance with your health plan benefits.

AETNA
 
Approved Behavioral Health Telemedicine Services

https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/bh-televideo-service-codes-covid-19.pdf

Behavioral Health and EAP Counseling; Video and Audio
Code Service Description
90791, 90792              Psychiatric diagnostic interview examination
90832, 90833, 90834, 90836, 90837, 90838      Individual psychotherapy
90839, 90840   Psychotherapy for crisis; first 60 minutes; or each additional 30 minutes
90845          Psychoanalysis
90846, 90847, 90853         Family or group psychotherapy
90863            Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services
 
Other Codes = see the website
 

March 20, 2020 - OCR Issues Guidance on Telehealth Remote Communications Following Its Notification of Enforcement Discretion
 
Today, the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) issued guidance on telehealth remote communications following its Notification of Enforcement Discretion during the COVID-19 nationwide public health emergency. 
The Notification, issued earlier this week, announced, effective immediately, that OCR is exercising its enforcement discretion to not impose penalties for HIPAA violations against healthcare providers in connection with their good faith provision of telehealth using communication technologies during the COVID-19 nationwide public health emergency. 
The new guidance is in the form of frequently asked questions (FAQs) and clarifies how OCR is applying the Notification to support the good faith provision of telehealth.  Some of the FAQs include:
  • What covered entities are included and excluded under the Notification?
  • Which parts of the HIPAA Rules are included in the Notification?
  • Does the Notification apply to violations of 42 CFR Part 2, the HHS regulation that protects the confidentiality of substance use disorder patient records?
  • When does the Notification expire?
  • Where can health care providers conduct telehealth?
  • What is a “non-public facing” remote communication product?
“We are empowering medical providers to serve patients wherever they are during this national public health emergency,” said Roger Severino, OCR Director.  “We are especially concerned about reaching those most at risk, including older persons and persons with disabilities,” Severino added.
The FAQs on telehealth remote communications may be found at:  https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf - PDF
The press release on telehealth remote communications may be found at: https://www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html
The Notification of Enforcement Discretion on telehealth remote communications may be found at: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
For more information on HIPAA and COVID-19, see OCR’s February 2020 Bulletin:  https://www.hhs.gov/sites/default/files/february-2020-hipaa-and-novel-coronavirus.pdf - PDF


March 19 - Thursday Updates on Telehealth and Billing
  • We have favorable updates today from Medicare and Medicaid. 
  • We should expect private payers to follow.
 
For Indiana = from the Governor's Proclamation and FSSA
  1. Effective immediately, covered mental health services will be reimbursed as if they took place in person.
  2. Telephone and telemedicine visits will be covered for both in- and out-of-state providers and for all covered services. 
Attached are:
  • The Indiana Telehealth Announcement
  • The Governor's Proclamation from today
Federal changes were also announced.
 
The link for these details from APA: https://www.apaservices.org/practice/reimbursement/government/medicare-telehealth-temporary-changes
 
Temporary changes to federal Medicare telehealth policies. 
  • Medicare patients are no longer required to be in an originating site and can now receive telehealth services in their own homes as well as in any health-care facility.
  • Telehealth is now available to Medicare beneficiaries in all parts of the country, not just in rural areas.
  • Telehealth services are reimbursed for the same dollar amount as in-person visits.
  • MS guidance states that HHS will not conduct audits to check whether a psychologists session was a new or a returning patient.
  • HHS will exercise enforcement discretion and waive penalties for HIPAA violations against providers who serve patients in good faith through everyday communication technologies, such as FaceTime or Skype, during this public emergency.
  • Telephones may be used only with audio and video functions that provide two-way real-time interactive communication. A telephone call without video does not qualify as a telehealth service. (Telephone-only sessions are reasonable and ethically appropriate in many circumstances, but they will not be reimbursed in Medicare at this point. APA will continue to advocate for telephone-only sessions.)
How to bill for telehealth services under Medicare
  • Psychologists should bill Medicare for telehealth services the same way they bill for an office visit by using the appropriate CPT® code for the service provided. 
While telehealth services in Medicare no longer require the use of a modifier, a specified place of service (POS) code, 02, must be used for all telehealth services regardless of where the psychologist is located.At this time,Medicare allows the following mental and behavioral health services to be provided via telehealth:
  • Interactive complexity (90785)
  • Psychiatric diagnostic interview (90791)
  • Psychotherapy including individual (90832, -34, -37), family (90846, -47), and psychotherapy for crisis (90839, -40)
  • Psychoanalysis (90845)
  • Health behavior assessment and intervention services, individual and group (96158, -59, -64, -65, -67, -68, -70, 71)
  • Neurobehavioral status examination (96116, 96121)
  • Psychologists can also bill for brief communications (known as e-Visits) with established Medicare patients. E-Visits involve a brief communication, typically initiated by the patient, and can be furnished in any location or geographic area. Medicare co-insurance and deductible amounts cannot be waived for e-Visits. 
    • To bill for an e-Visit, psychologists would use the following codes:
    • G2061: Qualified healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the seven days: 5-10 minutes.
    • G2062: cumulative time of 11-20 minutes during the seven days
    • G2063: cumulative time of 21 or more minutes during the seven days.
    • More information on e-Visits can be found here.


March 18 - Update on use and billing for Telepsychology and Videoconferencing

1.  Telepsychology is an active resource
Telepsychology, Telehealth, and Videoconferencing are quickly becoming understood and are now accepted nationwide.
 
2.  Medicare compensation
Medicare has announced telehealth services will be compensated for the duration of the COVID-19 Public Health Emergency, effective for visits back to March 6.
Details are located at:https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
 
3.  Payers Compensation
Most payers are now compensating for telehealth services. If not already doing so, regulatory agencies and the marketplace will likely influence them to pay providers.
 
4.  Examples of Payer coverage for Telehealth
Aetna will offer zero co-pay telemedicine visits for any reason. Aetna members should use telemedicine as their first line of defense . . . Cost sharing will be waived for all virtual visits . . . for all Commercial plan designs . . . Aetna will offer zero co-pay telemedicine visits for any reason . . . Aetna Medicare members should use telemedicine as their first line of defense . . . Cost sharing will be waived for all virtual visits . . . Members may use Teladoc for any reason . . .https://www.cvshealth.com/newsroom/press-releases/medicare-telemedicine-update-aetna-president-karen-s-lynch
BCBS (Blue Cross Blue Shield) will expand access to telehealth . . .BCBS companies will encourage the use of virtual care . . . and will also facilitate member access . . . These actions will apply to fully-insured, individual, and Medicare members of the 36 U.S. and Puerto Rico-based BCBS companies . . . are committed to working with state Medicaid and CHIP agencies. https://www.bcbs.com/coronavirus-updates
 
UnitedHealthcare is expanding our policies around telehealth services for our Medicare Advantage, Medicaid and commercial membership . . . UnitedHealthcare will waive the (CMS) originating site restriction for Medicare Advantage, Medicaid and commercial members, so that care providers can bill for telehealth services performed while a patient is at home . . . UnitedHealthcare will also reimburse providers for telephone calls to existing patients . . . For all UnitedHealthcare commercial plans . . . For all UnitedHealthcare Medicaid plans . . . For all UnitedHealthcare Medicare Advantage plans, including Dual Eligible Special Needs Plans, any originating site requirements that may apply under UnitedHealthcare reimbursement policies are waived so that telehealth services provided via a real-time audio and video communication system can be billed for members at home or another location.
https://www.uhcprovider.com/en/resource-library/news/provider-telehealth-policies.html

5.  CMS has softened their monitoring of HIPAA regulations.
The Office for Civil Rights (OCR) at . . . (HHS) is responsible for enforcing certain regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). During the . . . nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies. 
Some of these technologies . . . may not fully comply with the requirements of the HIPAA Rules. OCR . . . will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  This notification is effective immediately. 
https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html 
 
6.  Means of Videoconferencing for Telepsychology
Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. 
 
Under this Notice, however, Facebook Live, Twitch, TikTok, and similar video communication applications are public facing, and shouldnot be used in the provision of telehealth by covered health care providers.
Covered health care providers that seek additional privacy protections for telehealth while using video communication products should provide such services through technology vendors that are HIPAA compliant and will enter into HIPAA business associate agreements (BAAs). The list below includes some vendors who represent they provide HIPAA-compliant video communication products and will enter into a HIPAA BAA.
    • Google G Suite Hangouts Meet
    • Doxy.me
    • Zoom for Healthcare
    • VSee
    • Updox
    • Skype for Business
https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
 
7.Telepsychology - How To from APA
If you are new to Telepsychology, APA is offering a no-charge webinar series, Telepsychology Best Practices 101. There are four segments initially presented in October/November 2019.
https://apa.content.online/catalog/product.xhtml?eid=15132
 
8.Telepsychology - An effective resource
Given all this favorable information, telepsychology is effective and acceptable. When appropriate for your patient, please provide the service. Bill the payer as you normally would, using the appropriate codes and modifiers.