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Billing coding telehealth telemedicine services

3/17/2020

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​Understanding Telemedicine:
Telemedicine is the delivery of medical healthcare services using HIPAA-compliant and secure electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site, either with or without the assistance of an intervening health care provider for the purpose of diagnosis, consultation, and/or treatment of a patient. We need to understand though that Telemedicine does not include the use:
  • Electronic Mail or e-mail
  • Instant Messaging
  • Phone Texting
  • Facsimile Transmission
  • Audio-only Telephone Conversation

What a "Distant site" means - it is a site which the health care provider, working within their scope of practice and a valid license or certification, is located while providing health care services by means of HIPAA-compliant telemedicine technology.

What an "Originating site" means - it is a site at which a patient is located at the time that health care services are provided to the patient by means of telemedicine.

Synchronous means live (real-time live), two-way interaction between a person and a provider using audio-visual telecommunications technology.

Asynchronous also known as “store and forward” or “non-interactive telecommunication” means the acquisition and transmission of images, diagnostics, data, and medical information either to, or from, and originating site or to, or from, the healthcare provider at a distant site which allows for the patient to be evaluated without being physically present.

What are the covered services in Telemedicine? Well it depends on your insurance payers.

But you can find Medicare's guidelines here, CLICK HERE.

Other Payers?, you can scroll down as I have added several payers.

Common Modifiers used for Telehealth Services


Modifier 95
Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. Please refer to Appendix P within the American Medical Association’s Current Procedural Terminology (CPT®) code manual to review the CPT codes for which a "95" modifier can be used to indicate that the service was provided via a real-time, interactive audio and video telecommunications system.

​Modifier GT
Via interactive audio and video telecommunications systems

Modifier GQ
Services provided via asynchronous


** always check with your payers if the above Modifiers are acceptable based on their policy.
 Place of Service code use  02
*** check with your payers if POS 02 is applicable for telemedicine services based on their policy
Commercial and Private Payers Policy
PAYERS LIST IN ANY ORDER
CMS Medicare Guideline
Medicare Telehealth Covered CPT and HCPCS CODES. Click here.
Blue Cross Blue Shield of New Jersey - Telemedicine Services
The following lists of codes is provided as an informational tool only, to help identify some of the applicable CPT® codes/code ranges and HCPCS codes that may be utilized in reporting telemedicine services. The inclusion of a specific code does not indicate eligibility for coverage in all situations.

CPT Codes
90785, 90863, 96116, 90791-90792, 90832-90838, 90839-90840, 90845-90847, 90951-90961, 90963-90966, 90967-90970, 96150-96154, 96160-96161, 97802-97804, 99201-99205, 99211-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99354-99357, 99406-99407, 99408-99409, 99495-99496, 99497-99498

 HCPCS Codes
G0108-G0109, G0270, G0296, G0396-G0397, G0406, G0407, G0408, G0420-G0421, G0425-G0427, G0438-G0439, G0459, G0473, G0506, G0508-G0509, G0513-G0514, S0199

The following services are not eligible for reimbursement under this policy:
  • Non-direct patient services (e.g. coordination of care rendered before or after patient interaction) will not be considered for reimbursement.
  • Claims submitted with modifier GQ, which signifies services provided via asynchronous telecommunications system, as these services do not include direct in-person patient contact.
  • Any service that is not eligible for separate reimbursement when rendered to the patient in-person.
  • Presentation/origination site facility fee (HCPCS code Q3014).
  • CPT codes 99441-99444.
  • Health care providers providing telemedicine services shall be subject to the same standard of care or practice standards as are applicable to in-person settings.
  • Documentation in the medical record must be maintained and must support the services rendered.
  • Utilization review by Horizon BCBSNJ may be performed.
*** READ THE ENTIRE BCBS NJ POLICY HERE.
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Covid-19 medicare telehealth for providers

3/17/2020

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Medicare's Telehealth and Telemedicine Services during Covid-19. Understanding Provider and Non-Provider Services.
And Understanding
“Expansion of Telehealth with 1135 Waiver” 

COVID-19 Emergency Declaration Health Care Providers Fact Sheet
Understanding “EXPANSION OF TELEHEALTH WITH 1135 WAIVER” 

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So, under this Waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020 (date of service).  

Due to the Coronavirus (COVID-19) Public Health Emergency, doctors and other health care providers can use telehealth services to treat COVID-19 (and for other medically reasonable purposes) from offices, hospitals, and places of residence (like homes, nursing homes, and assisted living facilities) as of March 6, 2020. Medicare will pay for these services for patients who have seen the health care provider or another health care provider in the same practice.

These visits are considered as in-person visits and are paid at the rate as regular, in person visits.

Starting services rendered on March 6, 2020 and for the duration of the Covid-19 Public Health Emergency, Medicare will make payment for Telehealth Medicine Professional services rendered to Medicare beneficiaries in:
  • All Areas; 
  • All Facilities;
  • All settings in the country
  •  and in their HOMES.
Since the 1135 Waiver requires an established relationship, HHS however will not conduct an audit for all claims submitted during this public health emergency.

Deductible and Coinsurance will normally apply to these services. But the HHS Office of the Inspector General or the OIG is providing flexibility for healthcare Providers to reduce or waive cost-sharing for telehealth visits paid by the federal healthcare programs.

It is imperative during this public health emergency that patients avoid / should not travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness.  

Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act.  

Prior to this Waiver:
Medicare could only pay for telehealth on a limited basis:  that is; when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service. 

Changes in last year (2019), Medicare started reimbursing for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner. Medicare Part B separately pays clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal as well.

Effective date of service March 6, 2020:
Providers can provide and render Telehealth Medicine including Evaluation and Management visits (E/M common office visits), Mental Health Counseling and Preventive Health Screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to the doctor’s office or hospital which puts themselves and others at risk for Covid-19.

Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings.

While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, ​
Since the 1135 Waiver requires an established relationship, HHS however will not conduct an audit for all claims submitted during this public health emergency.

Question: Will I get Paid? as a Provider?  Answer:  YES based on MEDICAL NECESSITY!

We have 3 types of VIRTUAL SERVICES:
  • Telehealth visits
  • Virtual check-ins 
  • e-visits.

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Telehealth Visits:  
What’s required?
The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  
Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services is subject to State Law.

REMEMBER! - report using PLACE OF SERVICE is 02
Let’s identify the Providers Billable Services:

3 types of VIRTUAL SERVICES:
  • Telehealth visits
  • Virtual check-ins 
  • e-visits.


Telehealth Visits:  
What’s required?
The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  

Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services (check your State Law as this is subject to State Law) may include the following:
  • Physician
  • Nurse practitioner
  • Physician assistant
  • Nurse-midwife
  • Clinical nurse specialist
  • Clinical psychologist*
  • Clinical social worker*
  • Registered dietitian or nutrition professional
  • Certified registered nurse anesthetist
 
​Covered Telehealth Services CY 2020 (Updated 11/01/19)
​

Source: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
Virtual Check-ins visits may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image.


Virtual Check-ins visits:

Virtual check-ins can be used for the treatment for the Coronavirus (COVID-19) from anywhere, including places of residence (like homes, nursing homes, and assisted living facilities).

Virtual  check-in services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation. 

Must render only to established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image.
​

Services render via:
  • Phone
  • Audio/visit
  • Secure text messages
  • Email
  • Use of a patient portal

Here are your billable codes for Virtual Check-ins visits are as follows:

HCPCS code G2012 
Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
Requirements:
  • The service is communication technology-based
  • The provider can be a physician or other qualified health care professional who reports E/M services
  • Interaction must be between the patient and billing practitioner, not clinical staff.
  • The communication can’t be related to an E/M service from within the previous seven days.
  • The communication can’t lead to an E/M service within 24 hours (or soonest available): The language in the code descriptor states, “nor leading to an E/M service or procedure within the next 24 hours.” Consequently, Medicare will be watching for an uptick in appointments occurring 25 hours or so after the call. Do not game the system to get around the 24-hour limitation.
  • The code represents five to 10 minutes of medical discussion.
  • The medical record must document verbal consent from the patient for each billed service. Cost-sharing applies, and the beneficiary co-payment isn’t waived.
  • The service is available only to established patients, defined as patients who have “received professional services from the physician or qualified health care professional or another physician or qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.”

*** As being recommended by CMS to use G2012 for telehealth services. More information, click here.


HCPCS code G2010
Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M Evaluation and Management service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.

Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare Telehealth or Telemedicine visits, which require audio and visual capabilities for real-time communication.

e-visits services are only rendered via an online patient portal. ​
e-VISITS Services:  

E-visits services are only rendered via an online patient portal. 
These services can only be reported when the billing practice has an established relationship with the patient. 
This is not limited to only rural settings. There are no geographic or location restrictions for these visits.

Practitioners who may furnish these services include:
  • Doctors
  • Nurse practitioners
  • Physician assistants
  • Licensed clinical social workers, in specific circumstances
  • Clinical psychologists, in specific circumstances
  • Therapists, in specific circumstances​
​
  • e-visits can be used for the treatment for the Coronavirus (COVID-19) from anywhere, including places of residence (like homes, nursing homes, and assisted living facilities).
  • These services can only be reported when the billing practice has an established relationship with the patient.
  • For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. 
  • The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. 
  • The patient must verbally consent to receive virtual check-in services. 
  • The Medicare coinsurance and deductible would apply to these services.
  • Medicare Part B also pays for e-visits or patient-initiated online evaluation and management conducted via a patient portal
  • Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:​​
Your Billable Codes for e-visits are as follows:

CPT 99421: 
Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes

CPT 99422: 
Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes

CPT 99423: 
Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.


Clinicians who may not independently bill for evaluation and management visits . For example are:
  • Physical therapists
  • Occupational therapists
  • Speech Language pathologists
  • Clinical psychologists

They can also provide these e-visits and bill using the following codes:

HCPCS Code G2061: 
Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes

HCPCS Code G2062: 
Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes

HCPCS Code G2063:
Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.


For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html

For Medicare Beneficiaries, you can learn more about telehealth services here - https://www.medicare.gov/coverage/telehealth
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HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA):  Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. ​

For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html
HEADS-UP! - Use of GT modifier on Medicare claims was eliminated in 2018. According to CMS, the place of service code 02 is sufficient. 

Medicare Elimination of the GT Modifier for Telehealth Services - READ MLN Matters here.
To read more on Medicare Payment for Telemedicine. - CLICK HERE Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners

​190 - Medicare Payment for Telehealth Services
190.1 - Background
190.2 - Eligibility Criteria
190.3 - List of Medicare Telehealth Services
190.3.1 - Telehealth Consultation Services, Emergency Department or Initial
Inpatient versus Inpatient Evaluation and Management (E/M) Visits
190.3.2 - Telehealth Consultation Services, Emergency Department or Initial
Inpatient Defined
190.3.3 - Follow-Up Inpatient Telehealth Consultations Defined
190.3.4 – Payment for ESRD-Related Services as a Telehealth Service
190.3.5 – Payment for Subsequent Hospital Care Services and Subsequent
Nursing Facility Care Services as Telehealth Services
190.3.6 – Payment for Diabetes Self-Management Training (DSMT) as a
Telehealth Service
190.3.7 – Payment for Telehealth for Individuals with Acute Stroke
190.4 - Conditions of Payment
190.5 - Originating Site Facility Fee Payment Methodology
190.6 - Payment Methodology for Physician/Practitioner at the Distant Site
190.6.1 - Submission of Telehealth Claims for Distant Site Practitioners
190.6.2 - Exception for Store and Forward (Non-Interactive) Telehealth
190.7 - A/B MAC (B) Editing of Telehealth Claims

Timeline and Important Links: (source: CMS.GOV)
​For more information on telehealth benefits in the Medicare program, read the fact sheet:  https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf.

Summary of CMS Public Health Action on COVID-19 to date:

March 6, 2020, CMS issued frequently asked questions and answers (FAQs) for healthcare providers regarding Medicare payment for laboratory test and other services related to the 2019-Novel Coronavirus (COVID-19). https://www.cms.gov/newsroom/press-releases/covid-19-response-news-alert-cms-issues-frequently-asked-questions-assist-medicare-providers

March 5, 2020: CMS issued a second Healthcare Common Procedure Coding System (HCPCS) code for certain COVID-19 laboratory tests, in addition to three fact sheets about coverage and benefits for medical services related to COVID-19 for CMS programs.  https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests
​

March 4, 2020: CMS issued a call to action to healthcare providers nationwide and offered important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare. https://www.cms.gov/newsroom/press-releases/cms-announces-actions-address-spread-coronavirus
​

February 13, 2020: CMS issued a new HCPCS code for providers and laboratories to test patients for COVID-19.  https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test

February 6, 2020: CMS gave CLIA-certified laboratories information about how they can test for SARS-CoV-2. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/notification-surveyors-authorization-emergency-use-cdc-2019-novel-coronavirus-2019-ncov-real-time-rt
​

February 6, 2020: CMS issued a memo to help the nation’s healthcare facilities take critical steps to prepare for COVID-19.  https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/information-healthcare-facilities-concerning-2019-novel-coronavirus-illness-2019-ncov
​

For the updated information on the range of CMS activities to address COVID-19, visit:  https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
​
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Covid-19 telehealth SERVICES PAYERS COVERAGE

3/17/2020

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How are the Commercial Payers' Policy on Telehealth during this trying time due to Covid-19?
A3843 Requires health insurance and Medicaid coverage for testing of coronavirus disease 2019 and for telemedicine and telehealth during coronavirus disease 2019 state of emergency. - NJ State
READ NEW State of New Jersey Guideline A3843
​New York State Medicaid Coverage and Reimbursement Policy for Services Related to
Coronavirus Disease 2019 (COVID-19)
READ New York State Medicaid Coverage here
TRICARE covers the use of interactive audio/video technology services, and are subject to the same referral and authorization requirements and include, but are not limited to: clinical consultations, office visits and telemental health. CLICK HERE for more details.
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billing coding MEDICARE telehealth codes

3/17/2020

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Telehealth visits:  what’s required?
The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  
​

Distant site practitioners and clinicians who can furnish and get reimbursement for covered telehealth services (check your State Law as this is subject to State Law) may include the following:
  • Physicians
  • nurse practitioners
  • physician assistants
  • nurse midwives
  • certified nurse anesthetists
  • clinical psychologists
  • clinical social workers
  • registered dietitians
  • and nutrition professionals. 
Medicare Covered Telehealth Services CY 2020 (Updated 11/01/19) 
​Code  Short Descriptor
90785 Psytx complex interactive
90791 Psych diagnostic evaluation
90792 Psych diag eval w/med srvcs
90832 Psytx pt&/family 30 minutes
90833 Psytx pt&/fam w/e&m 30 min
90834 Psytx pt&/family 45 minutes
90836 Psytx pt&/fam w/e&m 45 min
90837 Psytx pt&/family 60 minutes
90838 Psytx pt&/fam w/e&m 60 min
90839 Psytx crisis initial 60 min
90840 Psytx crisis ea addl 30 min
90845 Psychoanalysis
90846 Family psytx w/o patient
90847 Family psytx w/patient
90951 Esrd serv 4 visits p mo <2yr
90952 Esrd serv 2-3 vsts p mo <2yr
90954 Esrd serv 4 vsts p mo 2-11
90955 Esrd srv 2-3 vsts p mo 2-11
90957 Esrd srv 4 vsts p mo 12-19
90958 Esrd srv 2-3 vsts p mo 12-19
90960 Esrd srv 4 visits p mo 20+
90961 Esrd srv 2-3 vsts p mo 20+
90963 Esrd home pt serv p mo <2yrs
90964 Esrd home pt serv p mo 2-11
90965 Esrd home pt serv p mo 12-19
90966 Esrd home pt serv p mo 20+
90967 Esrd home pt serv p day <2
90968 Esrd home pt serv p day 2-11
90969 Esrd home pt serv p day 12-19
90970 Esrd home pt serv p day 20+
96116 Neurobehavioral status exam
96150 Assess hlth/behave init
96151 Assess hlth/behave subseq
96152 Intervene hlth/behave indiv
96153 Intervene hlth/behave group
96154 Interv hlth/behav fam w/pt
96160 Pt-focused hlth risk assmt
96161 Caregiver health risk assmt
97802 Medical nutrition indiv in
97803 Med nutrition indiv subseq
97804 Medical nutrition group
99201 Office/outpatient visit new
99202 Office/outpatient visit new
99203 Office/outpatient visit new
99204 Office/outpatient visit new
99205 Office/outpatient visit new
99211 Office/outpatient visit est
99212 Office/outpatient visit est
99213 Office/outpatient visit est
99214 Office/outpatient visit est
99215 Office/outpatient visit est
99231 Subsequent hospital care
99232 Subsequent hospital care
99233 Subsequent hospital care
99307 Nursing fac care subseq
99308 Nursing fac care subseq
99309 Nursing fac care subseq
99310 Nursing fac care subseq
99354 Prolonged service office
99355 Prolonged service office
99356 Prolonged service inpatient
99357 Prolonged service inpatient
99406 Behav chng smoking 3-10 min
99407 Behav chng smoking > 10 min
99495 Trans care mgmt 14 day disch
99496 Trans care mgmt 7 day disch
99497 Advncd care plan 30 min
99498 Advncd are plan addl 30 min
G0108 Diab manage trn  per indiv
G0109 Diab manage trn ind/group
G0270 Mnt subs tx for change dx
G0296 Visit to determ ldct elig
G0396 Alcohol/subs interv 15-30mn
G0397 Alcohol/subs interv >30 min
G0406 Inpt/tele follow up 15
G0407 Inpt/tele follow up 25
G0408 Inpt/tele follow up 35
G0420 Ed svc ckd ind per session
G0421 Ed svc ckd grp per session
G0425 Inpt/ed teleconsult30
G0426 Inpt/ed teleconsult50
G0427 Inpt/ed teleconsult70
G0436 Tobacco-use counsel 3-10 min
G0437 Tobacco-use counsel>10min
G0438 Ppps, initial visit
G0439 Ppps, subseq visit
G0442 Annual alcohol screen 15 min
G0443 Brief alcohol misuse counsel
G0444 Depression screen annual
G0445 High inten beh couns std 30m
G0446 Intens behave ther cardio dx
G0447 Behavior counsel obesity 15m
G0459 Telehealth inpt pharm mgmt
G0506 Comp asses care plan ccm svc
G0508 Crit care telehea consult 60
G0509 Crit care telehea consult 50
G0513 Prolong prev svcs, first 30m
G0514 Prolong prev svcs, addl 30m
G2086 Off  base opioid tx first m
G2087 Off  base opioid tx, sub m
G2088 Off opioid tx month add 30 

Source: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
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medicare coinsurance deductible collection

3/17/2020

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​When Medicare is a Primary Insurance for the patient, the patient's part responsibility (coinsurance/deductible) normally crosses over to its secondary insurance for secondary coverage (if Medicare has the secondary insurance on file or if its set up to cross over based on the patient's coordination of benefits).

As you will notice on your Remittance advise, "Claim Information forwarded to: (insurance company here) Meaning, Medicare will forward the information to the secondary insurance. If not, try to find out if there is a secondary insurance for the patient, then you need to send the paper claim (using the HCFA 1500 form for Office/Provider/Professional Claims) to the secondary and attach a copy of the Medicare EOB (explanation of benefits). If your Practice Software can bill secondary to Medicare electronically, then that's great! Send them by electronic. 

If your practice management software is capable of doing this by electronic submission with attached copy of the EOB - much better!After you submit the claim to the secondary insurance, the secondary insurance EOB will then tell you if there is a copay being applied towards the patient being a secondary insurance after Medicare.You will then obviously collect that copay based on your contract with the secondary insurance company (and this is also based on the patient's contract with his/her secondary insurance). Medicare patients are mostly aware of their responsibility after the secondary insurance picks up.

Bottom line here:
(1) Medicare must process (not deny or reject!) the claim first being the primary;
(2) Secondary insurance must then process the claim with Medicare's claim information;
(3) Then, if there is a copay being applied towards the patient's responsibility -- you have to bill your patient for that copay!But honestly, I do not collect secondary insurance copay not until the secondary insurance had processed the claim (after Medicare's allowance!).

WHY? because it is possible that the patient may no longer have an active policy (at the time of service) with the secondary insurance, or maybe, there is no more copay because the patient had met his/her out of pocket limit. So to streamline this issue (of which not all offices are doing it) - you must always check benefits and eligibility for your patient's primary, secondary or even tertiary insurance coverage!It may be a lot of work too, but what I do is that, when I am billing the patient a copay (from the secondary insurance's determination and per the EOB) or even for their coinsurance!

I do my best to attach a copy of the EOB on the statement. That way, the patient has a copy of the said EOB and he/she will understand why I am billing him/her.
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CPT 99204 and cpt 99205 reporting billing

3/13/2020

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How do you describe CPT 99204?
Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive examination; medical decision making of moderate complexity. Counseling and/ or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
How do you report CPT 99205? - read below.
Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components: A comprehensive history; A comprehensive examination; Medical decision making of the complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family needs. Usually, the presenting problems(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family
CPT 99204 and or CPT 99205 Key Points:
  • Append Modifier 25 - if Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service 
  • DO NOT Append Modifier 59 - Distinct Procedural Service
  • DO NOT Append Modifier 33 - Preventive service
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ways to Improving Patient Access

3/11/2020

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​5 Mindful ways to Improving Patient Access

​Access is a significant concern in the United States and all over the world when it comes to patient care. We all know that the patients have to wait for months to get the physician they want, and a good doctor has more patients than they can manage. The patients waiting for months to get the physician surely lead to delayed treatment and also can jeopardize their health and their life. On the other hand, it will certainly reduce the patient satisfaction scores for the doctors and the medical service providers.

As these scores have to be shared with third parties such as pharmaceuticals and drug companies as well as the insurance companies, managing the scores is extremely significant for the doctors.

So here are a few ways that you can make sure your patients are not sitting and waiting for you to give them an appointment for half a year. 

Step 1:  Learn how to Measure
The first appointment available is a valuable commodity. So make sure that you have a good system to call people who are on the waiting list. Not just the first appointment available, but the second and third appointments available can also be prescheduled. You should inform the patients that are on the waiting list that they can be called in for a consult at short notice. When a person is coming up for the next available appointment, you can inform them that they are next on the list. That will allow individuals to prepare for showing up without feeling like it was impractical to ask on such short notice. 

Call people up or have a reminder system in place that will inform people on the list when they are next on the list of first appointment available. There are many openings happening every day, and placing then effectively can reduce overextended waiting lists considerably.

Step 2: Denied Appointment Requests
The patients who were denied an appointment is also a crucial list that needs to be monitored closely. There are many reasons that a patient is denied care, and those reasons should be listed clearly. If there is no appointment available or the appointment is not given for another reason, the reasons should be listed. That process will allow the nurses and administration to solve the problem and will allow them to develop a system that reduces denied appointments. 

Step 3: Implementation of the Data
The main focus of all of the points mentioned above is to have a system that focuses on developing data sheets on appointment schedules so that you can decide how to have a more productive appointment culture.

Here are a few steps you should take in the implementation process:
● Ask your administration about how they feel that they are being pushed too hard in the appointment process.
● Develop a severity scale of the patient’s complaint in the form of a questionnaire. The patient will answer the questionnaire on the phone, and the nurse or staff can decide how urgently they need to see the doctor.

Step 4: Effective Ways to Problem Solving
Find effective and simple solutions that will increase patient access on a daily basis. A few and simple tips on the matter are as follows:

● Have four backup appointments for every day that the patients have already been informed of. That way, the patient can simply come in if another patient cancels their appointment, and they will already be prepared for it.
● Patients on their second consult or with small concerns can come and see the doctor while the first patient is getting their physical. 
● If there is a list of symptoms common in the specialty of the doctor, then nurses can provide that list to the administrator. If a patient complains of these symptoms, then they will be called in by the nursing staff on an urgent basis.  
● Avoid letting worthy patients go to waiting lists for chronic complainers. Patients who have a tendency to over complaint can be seen and managed by the nursing staff. 

Step 5: Execute
Now, all it is left is to reorganize these concepts and make sure that they are implemented effectively. You will see amazing results with a small number of initiatives.

We are here for any ideas that you want to discuss. We are experts in the field.
Share your experiences with us in the comments section, and we would love to get back to you!
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2020 cpt changes genicular nerve 64624, 64454

3/9/2020

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How to Bill for Knee Genicular Nerve Branches RFA or Ablation, Destruction
Billing for the Genicular Nerve Branches RFA have been a struggle since it was not too clear to us on how we should be billing for this service. The good news is, we have a new code for this effective January 1, 2020. New CPT 2020 Changes. New Pain Management 2020 Codes.

When your physician is performing an RFA on Genicular nerves, use code 64624 (Destruction by neurolytic agent of genicular nerve branches). Take note of the word "branches".

These changes are explained as follows:
Destruction by Neurolytic Agent (eg, Chemical, Thermal, Electrical or Radiofrequency), Chemodenervation on the Somatic Nerves

CPT CODE 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed

(Do not report 64624 in conjunction with 64454 - Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed

Pay attention to this, the CPT 64624 requires the destruction of each of the following genicular nerve branches: (make sure your Provider had documented this!)
  • superolateral
  • superomedial
  • inferomedial

If a neurolytic agent for the purposes of destruction is not applied to all of these nerve branches, you can report CPT 64624 but you MUST append the MODIFIER 52:

64624-52

What is Modifier 52?

Modifier 52 is usually used for reduced services. It may occur under certain circumstances that a service or procedure is partially reduced or eliminated at the physician’s discretion. There can be several reasons behind the physician’s decision. In this situation, service provided can be identified by its usual procedure number and the addition of the modifier 52, which indicates that the service was reduced.

Understanding the 3 Genicular Nerve Branches of 64624

How to Bill for Knee Genicular Nerve Branches RFA or Ablation, Destruction
Image Source: https://ainsworthinstitute.com/genicular-neurotomy/
How to Bill CPT Code for Genicular Nerve Block RFA
What is the CPT code for  Knee Genicular Nerve Branches Block or Injection?

​Understanding the 3 Genicular Nerve Branches of 64454

What is the CPT code for  Knee Genicular Nerve Branches Block or Injection?
Source: https://ainsworthinstitute.com/genicular-neurotomy/
When your Physician is Blocking the Knee Genicular Nerves - here's your code: (pay attention with the imaging! it is included!).

CPT 64454 - Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches; (make sure your Provider had documented this!)
  • superolateral
  • superomedial
  • inferomedial

If all 3 of these genicular nerve branches are not injected, report 64454 with Modifier;
64454-52

What is Modifier 52?
Modifier 52 is usually used for reduced services. It may occur under certain circumstances that a service or procedure is partially reduced or eliminated at the physician’s discretion. There can be several reasons behind the physician’s decision. In this situation, service provided can be identified by its usual procedure number and the addition of the modifier 52, which indicates that the service was reduced.

Article Source: CPT Assistant December 2019 page 8 Destruction by Neurolytic Agent (Genicular Injection; Radiofrequency Neurotomy Sacroiliac Joint) For Current Procedural Terminology

Got additional questions or concerns? call us today!
Billing Tip: Always make sure you understand and you know the Medical, Clinical, Utilization and Reimbursement Policy of your Payers.

Read other blog posts:

How to Bill for 20553 with 76942 Ultrasound
Pain Management Nerve Blocks
How to Bill for Knee Genicular Nerve Branches RFA or Ablation, Destruction

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    ABOUT THE AUTHOR:
    Ms. Pinky Maniri-Pescasio is the Founder of GoHealthcare Consulting. She is a National Speaker on Practice Reimbursement and a Physician Advocate. She has served the Medical Practice Industry for more than 25 years as a Professional Consultant.

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