Billing and Reimbursement - HomeTown Health€¦ · A: 97802-97804 for Medical Nutrition Therapy...

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4/21/2020

Billing and Reimbursement

COVID-19 PHE

Paid Correctly!

Agenda

Billing and Reimbursement


4/21/2020

Reopening America’s Healthcare

Surgeries and

procedures,

chronic care, and

ultimately

preventative care

Need adequate

workforce, testing

and supplies in

case of a surge

Evaluate necessity

of care. Prioritize

surgeries and

complex care

needed

PPE should be

worn by staff and

patients without

jeopardizing your

supply in case of

surge.

Maximum use of

telehealth is

encouraged

In coordination

with state and

local public health,

evaluate trends

Consider non-

COVID treatment

zones with staff

and patient

screening.

Staff should be

tested and

quarantined if

symptomatic.

CMS recognizes

that hospitals may

not be in a surge

area and need to

reopen

Reopening America’s Healthcare

Staffing levels

must remain

adequate in case

of surge

Low patient

volumes, minimize

wait times, waiting

room chairs 6 ft

apart

Use thorough

cleaning and

sanitizing in all

areas

When able testing

should be used on

staff and patients

for screening

In person non-

emergent care

should be

performed away

from COVID care

Visitors prohibited

when possible and

screened if

necessary

Equipment

especially

ventilators should

be fully disinfected

after use

Continually

evaluate to make

sure you are in a

low COVID zone

Staff should not

work across both

zones


4/21/2020

Let’s Do This!

Information Overload!


4/21/2020

Don’t Panic!

We will discuss how to handle all of this information

Telehealth

Medicare Telehealth Codes

https://www.cms.gov/files/document/se20016.pdf

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes



4/21/2020

Who can provide Telehealth?

• Physicians

• Nurse practitioners (NPs)

• Physician assistants (PAs)

• Nurse-midwives

• Clinical nurse specialists (CNSs)

• Certified registered nurse anesthetists

• Clinical psychologists (CPs) and clinical social workers (CSWs) CPs and CSWs cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. They cannot bill or get paid for CPT codes 90792, 90833, 90836, and 90838.

• Registered dietitians or nutrition professional *Services must be within a provider’s scope of practice and consistent with Medicare benefit rules that apply to all services

• Per Palmetto GBA 4/17/2020

Do Not Use/Use For Telehealth

THE CR MODIFIER IS NOT REQUIRED

THE GT MODIFIER IS NOT USED FOR PART B

ONLY FOR METHOD II CAHS


4/21/2020

Use For Telehealth

THE DR CONDITION CODE MAY BE

USED AS TELEHEALTH IS A WAIVER UNDER 1135

USE MODIFIER CS FOR ALL COST

SHARE WAIVED SERVICES

https://www.youtube.com/watch?v=bdb9NKtybzo&feature=youtu.be

RHC Telehealth

• Guidance released Friday 4/17/2020

• Distant site telehealth services can be furnished by any health care practitioner working for the RHC or the FQHC within their scope of practice. Practitioners can furnish distant site telehealth services from any location, including their home, during the time that they are working for the RHC or FQHC, and can furnish any telehealth service that is approved as a distant site telehealth service under the Physician Fee Schedule (PFS)

https://www.youtube.com/watch?v=bdb9NKtybzo&feature=youtu.be



4/21/2020

RHC Guidance 4/17/20

• From January 27, 2020 to June 30, 2020

• Bill the telehealth as if it were a regular face to face visit using modifier 95.

• The telehealth visit will pay at $92

• The new rate will be paid retroactively after July 1st.

• After July 1st, the RHC will bill telehealth using the code G2025 to be paid at $92

• This extends as long as there is a PHE in effect

• Wrap around payments do not apply to these services

Important Information

Example:

Medicare RHC visit (AIR) -$160

Medicare telehealth$92

Recoupment -$68

If your current RHC AIR rate is > $92 when claims are reprocessed after July 1, 2020 that amount will

be recouped from Medicare payments.


4/21/2020

Virtual Check-ins - RHC

Communication, multiple methods, not video, Can be telephone, text message, email or patient portal

This is not telemedicine

Bill G0071 Do NOT use modifier 95!

Payment will be $24.76

Poll Question

Are your RHCs billing for telehealth?

• Yes

• No

• Not sure


4/21/2020

Accelerated Advance Payments - RHC

Qualified RHCs

• Request payment

from your MAC

• Recoupment will

begin at `120 days

Different Types of Visits


4/21/2020

Q: Has CMS given more guidance on telehealth for specialty nurses such as Wound Care, diabetic education etc.?

A: 97802-97804 for Medical Nutrition Therapy are on the approved list of telehealth codes. G0108 for Diabetic Mgmtis also on the list. Face to face services such as wound care are not.

Q:How do we bill them?

A: No definitive guidance but if they do not normally bill on a 1500 then bill on the UB.

Q: Can a hospital bill the Q3014?

A: If a beneficiary is at the hospital and receives telehealth services, the hospital can bill the Q3014

Medicaid Updates


4/21/2020

Iowa Medicaid Updates

• 4/16/2020 Iowa DCH is NOT waiving Prior Authorizations but is extending prior auths for elective services obtained prior to the emergency in 90-day increments until emergency is over.

• Effective 4/1/20 they are extending claims filing deadlines to 270 days from DOS.

• Telehealth Originating sites are where the patient is located and should bill Q3014 if in your facility (exception RHCs)

• Telehealth Distant sites are where the physician is located and should bill applicable CPT code and POS 02 with modifier 95.

• Drive Through testing sites should bill using POS 15 on the 1500 or hospitals should bill using Bill Type 141

Amerigroup Iowa

• Inpatient and respiratory care

• PA requirements are suspended for patient transfers: all hospital inpatient transfers to lower levels of care (by land only). Although PA is not required, Amerigroup requests voluntary notification via the usual channels to aid in our members’ care coordination and management.

• The 21-day inpatient requirement before transferring a patient to a long-term acute care hospital is suspended.

• Concurrent review for discharge planning will continue unless required to change by federal or state directive.

• PA requirements are suspended for COVD-19 DME, including oxygen supplies, respiratory devices and continuous positive airway pressure (CPAP) devices for patients diagnosed with COVID-19, along with the requirement for authorization to exceed quantity limits on gloves and masks.

• Respiratory services for acute treatment of COVID-19 will be covered. PA requirements are suspended where previously required.

• No information on Iowa Total Care

https://dhs.iowa.gov/sites/default/files/2129-MC-FFS-CVD_Timely_Filing_3.pdf?042020201457


4/21/2020

Georgia Medicaid GAMMIS

• Nursing Home Guidance 4/20/20

• Waiving Level I and Level II PASRR screenings

• Receiving facility has 30 days to complete

• Waiving 3-day stay if patient is displaced because of COVID-19 emergency

• DCH is suspending PAs only for non-elective inpatient hospitalizations only.

• CMOs are following FFS guidelines in most cases

GA Medicaid Telehealth Billing

• Providers that were billing for telehealth prior to the PHE will continue to use the designated codes associated with the service rendered and the GT modifier.

• Codes recently approved for the PHE will need to use POS code 02.

• You can verify which CPT codes need modifiers by using the procedure code search tab.


4/21/2020

Florida Medicaid Update

On Wednesday

Florida Webinar

Poll QuestionHave you seen a decrease in the volume of claims billed since the PHE was declared?

Yes, a big decrease

Yes, but not a big decrease

No, we are billing the same amount of claims


4/21/2020

Poll Question

If you have seen a decrease in claims, what are you using the extra time for?

Working outstanding AR

Working denials

I’ve been furloughed or laid off

I’m just enjoying not being so busy

Other, put in Q and A pane

Commercial Updates


4/21/2020

Anthem BCBS Updated 4/16

COVID-19 Tests and visits have cost-share waived through May 31st

Member cost-share waived for telehealth visits including mental health and substance use disorders

In-network providers can waive cost-sharing for telephonic only care

Cost-sharing waived for a visit to be tested, even if test not done beginning 3/18/20

Cost sharing includes co-pays, Co-insurance & deductibles

Anthem Reimbursement Methods

Inpatient and ER visits

• Contracted rates inclusive of co-pays and deductibles if visit is inclusive of COVID-19 testing or treatment

Drive-Through Labs – 87635 and U0002

• Fee schedule & cost sharing amounts


4/21/2020

Anthem Codes to Use

Effective 3/17 for therapy telehealth:

Physical therapy (PT) evaluation codes 97161, 97162, 97163, and 97164

Occupational (OT) therapy evaluation codes 97165, 97166, 97167, and 97168

PT/OT treatment codes 97110, 97112, 97530, and 97535

Speech therapy (ST) evaluation codes 92521, 92522, 92523, and 92524

ST treatment codes 92507, 92526, 92606, and 92609

For telephonic visits:

CPT codes 99441, 99442, 99443, 98966, 98967, 98968 and the place of service code that depicts where the provider’s telephonic-only services occurred.

For telehealth use POS 02 and modifier 95

Anthem Authorizations

Waived for patient transfers from Inpatient to SNF

21 day stay prior to transfer to LTCH suspended

Prior authorizations already obtained are extended to 90 days.

Concurrent reviews for discharge planning WILL continue.


4/21/2020

Audits and Reviews

Hospital claims audits requiring additional clinical documentation will be limited for the next 90 days

Retrospective reviews will be suspended but reserve the right to go back later

Timely filing requirements remain in place!

Aetna GA & FL

• Authorization for hospital admissions is waived for commercial and Medicare Advantage plans.

• Notify Aetna of admission within 48 hours

• If you want to submit clinical information you can

• Effective for 30 days through May 6th


4/21/2020

Aetna Iowa

• Waive member cost-sharing for inpatient admissions at all in-network facilities for treatment of COVID-19 or health complications associated with COVID-19. This policy applies to all Aetna-insured commercial plan sponsors and is effective immediately for any such admission through June 1, 2020.

• Waiving member cost-sharing for inpatient admissions at all in-network and out-of-network facilities for treatment of COVID-19 or health complications associated with COVID-19. This policy applies to all Aetna Individual and Group Medicare Advantage members and is effective March 25, 2020 for any such admission through June 1, 2020.

Aetna Telehealth

• Until June 4th, cost-sharing will be waived for telehealth for any diagnosis including virtual services and phone calls for commercial plans.

• Until further notice, zero-pay telemedicine visits for Individual & Group Medicare advantage plans for all diagnoses.

• Aetna reimburses all providers for telemedicine at the same rate as in-person visits.

• For telephone only codes (99441-99443, 98966-98968, G2010, G2012) there are reimbursement rates in the fee schedule that are not the same as E&M office visits 99201-99215. Given those telephone only codes do not equate to an office visit, they will not result in an office visit reimbursement rate.


4/21/2020

Aetna Billing• For commercial members non-facility

telemedicine claims must use POS 02 with the 95 or GT modifier.

• Facilities should continue to use their respective POS; CPTs and the telemedicine modifiers must be noted on the UB-04 form as the Rev Code will not be sufficient.

• For Medicare members, POS 02 or POS 11, or the POS equal to what it would have been had the service been furnished in-person, along with the modifier 95 indicating that the service rendered was actually performed via telehealth, may be utilized and will reimburse at the same rate.

Aetna Authorizations

Initial pre-cert and prior authorization for admission to post-acute settings (SNF, IRF) waived for a commercial and Medicare plans all states

Post Acute locations to notify Aetna within 48 hrs and send records within 3 days


4/21/2020

United Healthcare

• If a member receives treatment under a COVID-19 admission or diagnosis code between Feb. 4, 2020 and May 31, 2020, we will waive cost sharing (co-pays, coinsurance and deductibles) for the following:

• Office visits

• Urgent care visits

• Emergency department visits

• Observation stays

• Inpatient hospital episodes

• Acute inpatient rehab

• Long-term acute care

• Skilled nursing facilities

United Healthcare Authorizations

Until May 31, 2020

Discharges to SNF, Home Health, other PAC settings do not require prior Authorization

Receiving facility needs to notify within 24 hours

Inpatient admissions notify within 24 hrs or by 5 pm Monday for weekend admissions


4/21/2020

United Healthcare Diagnostic Radiology

• Will not require prior authorizations for diagnostic radiology (diagnostic imaging) of the chest for COVID-19 patients during this national emergency.

• Urge providers to submit notification for CPT® codes 71250, 71260, 71270 for members with a COVID-19 diagnosis or suspected diagnosis, and who are enrolled in Medicaid and Individual and Group Market health plans.

• No notice is necessary for Medicare.

• Other chest CT scans continue to require prior authorization

United Healthcare Lab Billing

• UHC Does not recognize the distinction between CPT codes!!

• ONLY Use 87635 for ALL COVID-19 lab testing!

• Bill with the following ICD-10 Codes

• Suspected exposure to someone with Coronavirus use Z03.818

• Actual exposure to someone with Coronavirus use Z20.818


4/21/2020

United Telehealth

• Effective from March 31, 2020 until June 18, 2020, they will waive cost sharing for in-network telehealth visits for medical, outpatient behavioral and physical, occupational and speech therapy services (PT/OT/ST)

• UnitedHealthcare is waiving the Centers for Medicare and Medicaid’s (CMS) originating site restriction and audio-video requirement for Medicare Advantage, Medicaid, and Individual and Group Market health plan members from March 18, 2020 until June 18, 2020. Eligible care providers can bill for telehealth services performed using interactive audio-video or audio-only, except in the cases where we have explicitly denoted the need for interactive audio/video, such as with PT/OT/ST, while a patient is at home.

Telehealth + Billing United

• Allowing all codes on the CMS Covered Telehealth list

• Scheduled telehealth visit with an established patient use 99211-99215 with POS 11, 20, 22, 23 and modifier 95

• E-visit through online portal – Use 99421-99423 with POS 11, 20, 22, 23, no modifiers required

• Virtual Check-in – Use G2012 with POS 11, 22, 20, 23, no modifiers required


4/21/2020

United Healthcare Therapy Telehealth

• PT/OT/ST Codes that can be billed for telehealth through June 18, 2020

• Must be a live audio/visual visit

• No pre-recorded exercise videos

• No phone only visits

• There is no change to utilization management requirements for physical, occupational or speech therapy services. You should continue to comply with these requirements.

United Healthcare • Starting March 31, 2020 until June 18,

2020, UnitedHealth will also waive cost sharing for in-network, non-COVID-19 telehealth visits for its Medicare Advantage, Medicaid, and fully insured individual and group market health plans.

https://www.uhcprovider.com/content/provider/en/viewer.html?file=%2Fcontent%2Fdam%2Fprovider%2Fdocs%2Fpublic%2Fresources%2Fnews%2F2020%2Fcovid19%2Ftelehealth-services-pt-ot-st.pdf


4/21/2020

Humana Policy Changes

• Suspending pre and post-payment reviews

• Releasing claims under medical record review

• Reserve the right to do retro reviews

• Individual, Medicare Advantage, Medicaid & Commercial

• Sequestration is suspended until 12/31/2020

Humana

• Suspending nearly all pre-authorization requirements for participating/in-network providers. This applies to inpatient (acute and post-acute), outpatient, and all referrals for Humana’s individual and Group Medicare Advantage, Commercial Group, and Medicaid plans.

• Applies to both participating/in-network and non-participating /out-of-network providers when the member has a COVID-related diagnosis

• Non-par/out-of-network providers must continue to follow referral requirements and submit authorization requests per Humana’s policy

• Please continue to submit a notification as normal when your Humana-covered patients are admitted to the hospital, even when authorization is not required.

• Humana is extending previously approved authorizations to a 90-day approval timeframe, except for home health authorizations, which are being extended for 60 days.


4/21/2020

Humana Lab CPT codes for billing

• For COVID-19 testing use U0001, U0002 and 87635

• Testing for other viral respiratory conditions to rule out COVID-19 use:

• CPT 87804 – Infectious agent antigen detection by immunoassay with direct optical observation; influenza

• CPT 87633 – Respiratory virus panel

• CPT 87486 – C. pneumoniae CPT 87581 – M. pneumonia

• The applicable ICD-10 code must also be on the claim

Cigna

Waiving cost-sharing for COVID-19 testing related visits until May 31stWaiving

Waiving prior authorizations for transfers of non-COVID-19 patients to LTAC to make room for COVID-19 surge patients

Waiving


4/21/2020

Poll QuestionDo you currently have COVID-19 positive patients in your hospital?

Yes < 5 inpatients

Yes > 5 inpatients

No, we had some but no longer do

No, we haven’t had any COVID-19 patients

I have no idea

Coding Guidance

From CDC.gov


4/21/2020

ICD-10 Coding Guidance

• J12.89 – Other viral Pneumonia & B97.29 Other coronavirus as the cause of disease

Pneumonia Related to COVID-19

• J20.8 – Acute Bronchitis & B97.29

• NOS – J40 – Bronchitis & B97.29

Bronchitis Related to COVID-19

• J22 – Unsp. Lower Resp. Infection & B97.29

• NOS – J98.8 Resp. Disorder & B97.29

Acute Lower Respiratory Infection with COVID-19

• J80 – Acute Resp. Distress & B97.29

ARDS due to COVID-19

ICD-10 Coding Guidance

Exposure to COVID-19

• Ruled out use – Z03.818 – Encounter for observation of suspected exposure ruled out

• Actual exposure – Z20.828 – Contact with and suspected exposure to viral communicable disease

Signs & Symptoms no definitive Dx

• R05 – Cough

• R06.02 – Shortness of breath

• R50.9 – Fever

Not Appropriate for COVID-19

• B34.2 – Coronavirus unspecified

If documented Probable, possible, suspected COVID-19 do not code B97.29

• Assign a code for the symptoms instead

https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf

https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf


4/21/2020

Modifier CS for Medicare

• Any service related to COVID-19 testing including telehealth will be covered.

• For services related to COVID-19 the co-insurance will be waived.

• Put the CS modifier on the service line and Medicare will pay 100% of the allowed amount.

• Do not collect from the patient.

• Telehealth claims will be reprocessed after July 1st if they were paid incorrectly.

• Refund any COVID-19 related money collected.

Example: Patient presents to ED & because of symptoms is tested for COVID-19.

Patient is also charged ED level, influenza A & B test, strep test, & urinalysis.

Patient is negative for COVID-19 & diagnosis is sinusitis. What lines do we append CS modifier?

All CPT code lines for payers who require them for cost-sharing waivers. Also coders need to code symptoms related to COVID-19

Also, does the CS modifier apply on inpatients?

No, CPT codes are not reported on inpatients so modifiers do not apply


4/21/2020

Specimen Collection

•Specimen collection codes for COVID-19 testing

•G2023 and G2024

•Only for Independent Lab billing

New CPT codes for Antibodies

https://www.ama-assn.org/system/files/2020-04/cpt-assistant-guide-coronavirus-april-2020.pdf

https://www.ama-assn.org/system/files/2020-04/cpt-assistant-guide-coronavirus-april-2020.pdf


4/21/2020

Self-Pay Patients

How do we manage these patients?

• We cannot balance bill self pay patients

• Most hospitals do not send self-pay through the clearinghouse

• Check with your vendor to see if the claims can go through edits before going to your early out vendor.

• If a self-pay patient has any COVID related testing or treatment you cannot send them a statement for money owed.

• Edits should pick up any COVID CPT codes and/or ICD-10 codes


4/21/2020

Edits for all patient

Hold claims with these

codes

All insurance

and self-pay

• ICD-10 codes

• J12.89

• J20.8

• J22

• J40

• J80

• J98.8

• R05

• R06.02

• R50.9

• B34.2

• B97.29

• Z03.818

• Z20.828

• U07.1

• CPT Codes

• U0001

• U0002

• 87635

• 71250

• 71260

• 71270

• 71035

When the claim hits an edit…

Check to see who the payer is or

if the patient is uninsured, and

the type of service.

Check the payer guidelines for

the type of service. Correct the

insurance claims

If the patient is uninsured and

the treatment or testing is

related to COVID-19 adjust the

account to zero.

01 02 03


4/21/2020

COVID-19 Uninsured Claims

Run a report for all COVID-19 Lab charges or pull the COVID-19 Lab log

Review billing for all patients who have had a COID-19 test.

Check patient logs for prior visits where symptoms may not initially have resulted in a COVID-19 test. Minimum back to 3/1/20

Contact your early out vendor and pull back & close any COVID-19 self-pay accounts

If patients call the vendor have a contact person for them at the hospital business office who can help them.

COVID-19 Uninsured Claims

• Clinic visits

• Drive Through testing

• Telehealth patients

• Ambulance patients

Don’t forget your alternative sites

Create a new adjustment code for writing off uninsured COVID-19 patient accounts

It is important to track these for HHS payment tracking

Main purpose of funding is to allow you to write off these accounts


4/21/2020

Real Life Example

• Patient comes to the ER on March 2, 2020 with complaint of a cough and is sent home with Rx.

• Patient returns to ER on March 3, 2020 via EMS with worsening cough and is again sent home.

• Patient returns the evening of March 3, 2020 and COVID-19 testing is done and the patient is admitted to inpatient with suspected COVID-19 virus.

• ALL 4 accounts are related to the COVID-19 testing and services.

• If the patient is uninsured, all charges will be written off.

• If the patient has insurance, cost sharing will be waived and specific billing rules will apply based on the payer.

Condition Code DR

• The DR modifier is to be used on all Medicare claims that are related to a COVID-19 waiver.

• Waivers include:

• SNF 3 day stay

• CAH hospital bed and hours

• PPS hospitals housing patients in other units


4/21/2020

[email protected]

Questions?

Additional Resources

• https://www.uhcprovider.com/content/provider/en/viewer.html?file=%2Fcontent%2Fdam%2Fprovider%2Fdocs%2Fpublic%2Fresources%2Fnews%2F2020%2FTelehealth-Patient-Scenarios.pdf

• https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/

• https://www.ihaonline.org/Coronavirus_Billing_and_Financial_Resources

https://dhs.iowa.gov/ime/providers/faqs/covid19/telehealth

https://dhs.iowa.gov/sites/default/files/2115-MC-FFS_Billing_related_to_COVID-19.pdf?042020201507

https://www.uhcprovider.com/content/provider/en/viewer.html?file=%2Fcontent%2Fdam%2Fprovider%2Fdocs%2Fpublic%2Fresources%2Fnews%2F2020%2FTelehealth-Patient-Scenarios.pdf

https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/

https://www.ihaonline.org/Coronavirus_Billing_and_Financial_Resources

https://dhs.iowa.gov/ime/providers/faqs/covid19/telehealth

https://dhs.iowa.gov/sites/default/files/2115-MC-FFS_Billing_related_to_COVID-19.pdf?042020201507

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