4 Ways to Avoid Telehealth Denials

COVID-19 ushered in a nationwide expansion of telehealth services. As a result, patients were able to see their doctors even when they were socially isolated or on stay-at-home orders. All of this was—and continues to be—good news for patient outcomes, care continuity, and chronic care management.

Many medical clinics are still embracing telemedicine, but payers are beginning to crack down on non-compliant billing. Medicare, commercial payers, and even the Office of Inspector General have begun to examine telehealth claims more closely in the hopes of avoiding denials.

According to Joseph L. Rivet, MD, if medical practices want to offer telehealth in the long run, they'll need a revenue-integrity strategy.

"This is easier said than done because payers' payment policies appear to change constantly," he adds.

Rivet offers four pointers to keep practices on track when it comes to telehealth billing:

1. Pay close attention to the POS codes and modifiers

Not all payers follow the same regulations. Think about Medicare. Report POS 11 (physician office) and modifier -95 for new or existing patient telehealth office visits (synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system). Report modifier -CS (cost sharing waiver) if the telehealth office visit is for COVID-19-related care.

Practices must, however, check with each individual payer for commercial payers and Medicare Advantage plans. Some payers, for example, may have specific requirements Some payers, for example, may demand POS code 02 (telehealth supplied outside of the patient's home) and/or modifier -95, -GQ (telehealth service rendered via asynchronous telecommunications system), or -GT (telehealth service rendered via asynchronous telecommunications system) (telehealth service rendered via interactive audio and video telecommunications system).

There is one caveat: some adjustments will go into effect on April 4, 2022. Specifically, providers will no longer record POS 11 for new or existing patient telehealth office visits. Instead, they'll report POS 10 (patients with Medicare who are receiving telehealth services at home) or POS 02 (patients with Medicare who are receiving telehealth services at home).

If a patient receives telehealth services while in a rehabilitation unit following surgery, for example, POS 02 will be appropriate. Commercial insurers and Medicare Advantage plans may or may not participate.

2. Make sure you're billing for a telehealth service.

Medicare has published a list of telehealth services that are covered under the Medicare Physician Fee Schedule. This list, however, is not followed by all commercial payers and Medicare Advantage plans. It is recommended to request a copy of each payer's telehealth policy, which should contain a list of CPT codes that are deemed payable when given via telehealth.

3. Make a grid for accurate billing.

List each payer, as well as any POS code, modifier, or other documentation needs. Practices can utilize this grid as a starting point for making adjustments in their practice management system. The ultimate goal is to maximize revenue integrity and have a clean claim go out on the first submission.

4. Keep an eye on telehealth.

Keeping a careful eye on denials can assist practices guarantee that appeals are filed on time. It also aids practices in avoiding recurring errors that could affect revenue. Perhaps a payer's telemedicine policy changed, and the practice was unaware that it required to utilize a different modifier on virtual office visit claims. It's possible that denials are the sole sign that something has changed.

The best strategy is to sign up for each payer's list serve to obtain early notifications of telehealth coding and billing changes. Keeping a careful eye on denials can assist practices guarantee that appeals are filed on time. It also aids practices in avoiding recurring errors that could affect revenue. Perhaps a payer's telemedicine policy changed, and the practice was unaware that it required to utilize a different modifier on virtual office visit claims. It's possible that denials are the sole sign that something has changed. The best strategy is to sign up for each payer's list serve to obtain early notifications of telehealth coding and billing changes.

Conclusion

Focusing on coding and billing compliance is critical as medical practices extend their telemedicine offerings. Tracking POS codes, modifiers, and telehealth payment services for each payer is a critical aspect of a good revenue integrity compliance program—especially as payers become more sophisticated.