The Elephant in the Room: No Standardization in Telehealth Coding

The Elephant in the Room: No Standardization in Telehealth Coding

A telehealth claim during the COVID-19 Public Health Emergency (PHE) is submitted to the primary plan, a commercial plan that requires Place of Service (POS) code 02 or 10 and modifier -95. The claim applies to the deductible. The patient has Medicare as his secondary plan, and the telehealth claim is duly forwarded to Medicare without changing the telehealth place of service coding.

Medicare pays, but reduces the allowable amount due to the telehealth coding not being consistent with the PHE requirement of pre-pandemic POS code.

Providers must accept lower reimbursement for services, because The Powers That Be can’t (won’t?) get together and agree on how telehealth should be submitted? It’s the middle of 2022. Haven’t we lived with COVID and telehealth now for long enough that they should have figured this out?

It would be fraud to change coding on the claim after the primary plan considers it, right?

The opposite also happens:

A provider submits a telehealth claim to Medicare using the PHE coding.  Medicare pays correctly and forwards the claim to the secondary payer, which is not a Medigap plan. In mental health billing, some commercial insurance plans use specialty behavioral health vendors known as “carve-outs,” where the entity who pays mental health claims is independent of the insurer who handles the medical benefits. This plan was one such. Because non-Medigap plans do not have to follow Medicare guidelines, the secondary payer in this case didn’t adjudicate the claim but denied it back to the provider stating they were not the correct payer. The provider is then required to file a manual claim to the secondary payer’s behavioral carve-out to obtain reimbursement.  This was done without changing the telehealth coding, and the behavioral plan denied the claim: INCORRECT CODING. An appeal was submitted explaining that the provider was following Medicare guidelines, and included a copy of Medicare’s directive for coding PHE telehealth claims. The appeal upheld the denial: “the telehealth coding is incorrect.”

The provider was acting ethically by not adjusting coding after the fact. Now she must lose out on the reimbursement – because it certainly would not be fair to charge the patient.

Is there a solution here?  Can coding be changed ethically? Is it fraud? Abuse?

I asked Chad Schiffman, Director of Compliance and Risk Management at Healthcare Compliance Pros.

He first clarified the difference between “fraud” and “abuse,” which I think is an important distinction. In his words,

“Medical billing fraud and abuse arises mainly due to medical coding and

billing errors which lead to improper reimbursements. Fraud is a deliberate

deception that results in an unauthorized payment, while abuse is failing to

adhere to accepted business practices.”

It seems that we’re not contemplating fraud here – if you provided a telehealth service, that’s what you provided and there is no deception.

Mr. Schiffman agreed.

“It would not be considered fraudulent if the medical record

documentation supports the … claim being submitted, and the

code was just being updated with a corrected code.”

But he cautioned that providers need to:

1) refrain from altering the documentation after the fact, just to support a corrected claim; and

2) make sure that the codes on the corrected claim do in fact reflect the medical record.

Abuse seems to be the issue here: failing to adhere to accepted business practices. in this instance, accepted practice is to keep codes consistent between the primary and the secondary payer.

I also asked Mr. Schiffman about the two scenarios above.

“I discussed these scenarios with our Coding and Auditing Manager. On the

first scenario, she pointed out because it applies to the deductible, she is

uncertain if Medicare will allow the coding to be changed and resubmitted.

We looked for guidance and came up blank on that. She recommends

contacting the MAC, explaining the scenario, and seeing if they allow a

corrected claim after it was already submitted to the commercial payer.”

“For scenario 2, while we do not see an issue from a compliance perspective

correcting and resubmitting the claim to the secondary payer, we would

recommend contacting the payers directly and seeing if they allow it or

what their process is.”

Ok, so if the best minds in Compliance “came up blank,” then how is a solo provider, with no coding background and no staff, supposed to get it right?

Good point! My advice: proceed with caution.

While contacting the MAC or a private payer seems to be a logical step, most likely the customer service rep will tell you that they are not allowed to tell providers how to code. They will say “code according to your documentation and best practices.” Which puts you right back where you started. And even if you did, by some chance, get a CSR to answer you…what guarantee do you have that this rep gave you the correct answer? In an audit, would that stand up?

My recommendation is to play it safe: unless the MAC or private payer is willing to answer your question and give you permission in writing … then, don’t.

Yes, it’s unfair, and it sucks not to be fully paid – but the consequences of altering coding between a primary and secondary payer could be far worse.

Tired of being short-changed?

I don’t blame you – it’s unjust.

Are the professional organizations aware of the elephant in the room? What are they doing to rehome him back into the wild, and represent you?

Getting Paid for Telehealth

Getting Paid for Telehealth

Trying to figure out how to get paid for telehealth? *

*Doing audio-only? Coding and policies for audio-only telehealth are different. This blog focuses only on two-way audio/video telehealth.

If you thought it was bad in 2021, when you just had to deal with whether to use Place of Service (POS) 02 versus 11, and modifier -GT versus -95, now there’s a new complication.

Announced by CMS on October 13, 2021, the new place of service code (POS) for telehealth is 10, and it indicates telehealth when the patient is receiving services at home. Meanwhile, POS 02 has been shifted to denote that the patient is somewhere other than at home.

Don’t ask me why they felt it was necessary to make this distinction…

Next year, there will be a place of service for the bathroom.

When announcing the new POS 10, CMS originally stated that the implementation date for Medicare was April 4, 2022. However, the renewal of the Public Health Emergency (PHE) on April 13, 2022, trumps Medicare’s implementation of POS 10, because, according to the emergency waivers issued at the start of the COVID-19 pandemic, the telehealth flexibilities put in place as of March 6, 2020, will last until the end of the PHE (currently set for July 15, 2022).

Therefore, until the declared end of the PHE, coding telehealth for Medicare is still POS 11 (or whatever POS you would have used prior to the pandemic), plus modifier -95. This also applies to Medicare Advantage and Dual (Medicare + Medicaid) commercial plans.

Note: Medicare will pay for POS 10 (and 02) during the PHE, but coding POS 02 or 10 will impose a rate reduction.

This is because according to pre-pandemic Medicare telehealth policy, telehealth was subject to fee reductions. Medicare instituted the COVID telehealth billing flexibilities so as not to have to reprogram their payment systems, and also to ensure that healthcare providers could stay in business – sort of an important consideration during a worldwide pandemic.

What about commercial payers?

That’s the problem. Unlike Medicare and other government payers for whom billing instructions are a matter of public record, private payers don’t always openly disclose what they expect regarding telehealth coding – or they do, but it is often unclear, incomplete, and/or they make it so hard to find that it takes hours of searching.

Why is this so difficult? I just want to know how I can get paid for telehealth! Why can’t they all agree on how to bill it?

If I had the answer and solution to this problem, I would be able retire to Bora Bora tomorrow and you would have to find another Billing Buddy.

It’s frustrating, but right now everything depends on the payer and the policies they have implemented with regard to billing for telehealth. Some payers simply follow the lead of CMS. Others do their own thing…and they aren’t always consistent about it, either.

Your Billing Buddy’s recommendations for commercial payers:

  • Check the payer’s website to see what (if any) instructions exist regarding billing for telehealth. I typically start by looking at the links marked “COVID-19” and then clicking around randomly until I get to information about telehealth and, hopefully, information about how to bill it.
  • If you DO find something definitive, print it out. This will give you a snapshot of the date you obtained the information. Save it – you never know when you might need it in case of a clawback / recoupment attempt.
  • Maintain a log or spreadsheet of the telehealth billing policy / coding requirements of the payers you bill most often.
  • If you have time, feel free to call the payer, just don’t be surprised if it takes you a long time on the phone and at the end of the call you are more frustrated (but no more enlightened) than you were an hour or two previously.
  • Subscribe to payer newsletters, blogs, and watch for webinars and trainings they offer.
  • When in doubt, stick with POS 02 as long as the PHE remains in effect.
  • If am unsure whether POS 10 is acceptable yet, but think it appropriate to try, I send in one test claim. I make note on my spreadsheet of the patient account #, date of service, and date submitted. Then, before submitting any more, I wait until it is adjudicated. Once I have my answer, I correct and release the remainder of claims that I have put on hold. That way, if the claim does get denied or underpaid, a single claim can be corrected quietly, without a large number of claims needing correction.