4 Tips to Avoiding Telehealth Denials During COVID-19 and Beyond

With COVID-19 came a rapid expansion of telehealth services nationwide. As a result, patients were able to access their physicians even during times of social distancing and stay-at-home orders. All of this was—and still is—good news for care continuity, chronic care management, and patient outcomes.

Many medical practices continue to embrace telehealth; however, payers are also starting to crack down on non-compliant billing. In particular, Medicare, commercial payers, and even and the Office of Inspector General have begun to take a closer look at telehealth claims with an eye toward prospective denials.

If medical practices intend to offer telehealth in the long-run, they’ll need to a strategy to ensure revenue integrity, says Joseph L. Rivet, Esq., principal attorney at Rivet Health Law, PLC in Norton Shores, Michigan. “This is easier said than done because payers seem to be modifying their payment policies frequently,” he adds.

Rivet provides four tips to help practices stay on the right track when billing for telehealth:
 

1. Pay attention to place of service (POS) codes and modifiers.


Not all payers follow the same rules, says Rivet. Consider Medicare. For new or established patient telehealth office visits, report POS 11 (physician office) as well as modifier -95 (synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system). If the telehealth office visit is for COVID-19-related care, report modifier -CS (cost sharing waiver) as well.

However, for commercial payers and Medicare Advantage plans, practices need to check with each specific payer. Some payers, for example, may require POS code 02 (telehealth provided other than in the patient’s home) and/or modifier -95, -GQ (telehealth service rendered via asynchronous telecommunications system), or -GT (telehealth service rendered via interactive audio and video telecommunications system).

One caveat is that some changes will take effect on April 4, 2022. More specifically, for new or established patient telehealth office visits, providers will no longer report POS 11. Instead, they’ll report either new place of service (POS) code 10 (patients with Medicare are in their home while receiving telehealth services) or POS 02.

For example, POS 02 will be appropriate if the patient receives telehealth services while in a rehabilitation unit post-surgery. Again, commercial payers and Medicare Advantage plans may or may not follow this new guidance.


2. Ensure you’re billing a ‘telehealth covered’ service.


Medicare has posted its list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth. However, not all commercial payers and Medicare Advantage plans follow this list. Rivet suggests asking each payer for its telehealth policy that includes specific CPT codes that are considered payable when rendered via telehealth.
 

3. Create a grid for compliant billing.


List each payer along with any requirements for POS codes, modifiers, and any additional documentation. Practices can also use this grid as a foundation for creating edits in their practice management system, says Rivet. “The ultimate goal is to increase revenue integrity and have a clean claim go out on the first submission,” he adds.
 

4. Monitor telehealth denials.


Keeping a close eye on denials helps practices ensure timely appeals. It also helps practices avoid continued errors that can jeopardize revenue. For example, perhaps a payer changed its telehealth policy, and the practice didn’t realize it needed to use a different modifier on telehealth office visit claims. Denials may be the only clue that something changed. Best practice is to sign up for each payer’s list serv so the practice receives timely notifications of telehealth coding and billing changes, says Rivet.


Conclusion

As medical practices continue to expand telehealth services, focusing on coding and billing compliance is paramount. Tracking POS codes, modifiers, and telehealth payable services for each payer is an important part of a healthy compliance program centered on revenue integrity—particularly as payer telehealth policies continue to evolve. For a reliable and private telehealth solution, check out what Kareo has to offer here. 

About the Author

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a...

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