A Comprehensive Guide to Telehealth Billing 2023

Posted on October 27th, 2023 / Under Medical Billing / With No Comments

COVID-19 has brought multiple changes into our daily lives; one of those changes is a growing number of people opting for telehealth. Compared to 2019, when only 10% of people actively acquired telehealth services, a recent survey shows that approximately 52% of adults use telemedicine.

Post-pandemic, there was a surge in demand for telehealth services because many patients deem it a more convenient option than in-person visits. Now, approximately 76% of healthcare organizations in the U.S. allow patients to consult with providers virtually. 

Telemedicine is significantly different today from what it was pre-pandemic. Even the recent legislation by the U.S. Department of Health and Human Services authorized multiple changes, some of which are permanent.
In this guide, we’ll help you navigate medicare telehealth billing guidelines 2023, including updated telehealth CPT codes, telemedicine modifiers, and reimbursement for telehealth.

Telemedicine is significantly different today from what it was pre-pandemic. Even the recent legislation by the U.S. Department of Health and Human Services authorized multiple changes, some of which are permanent.
In this guide, we’ll help you navigate medicare telehealth billing guidelines 2023, including updated telehealth CPT codes, telemedicine modifiers, and reimbursement for telehealth.

What Is Telehealth? 

Telehealth, also known as telemedicine, is a term used to describe the use of telecommunication and electronic information to address health needs. Common technologies to extend care include streaming media, wireless communications, and video conferencing. Telemedicine billing services can vary depending on your geographic location and the insurance provider or payer you are billing.

Benefits of Using Telehealth

One main reason people were using telehealth during COVID-19 is because it eliminated the travel burden for patients who were vulnerable to the virus. Other than that, telehealth provides multiple benefits, including,

1. Vital details of a patient’s health can reach their assigned caretakers and healthcare team in time with the help of health monitoring services. 
2. People struggling with poor mental health can seek online therapy services. 
3. You can partner with telepharmacy services to deliver prescriptions to your patient’s doorstep. 
4. With telehealth, uninsured patients are billed by providers at a price similar to a normal insurance copay, expanding their access to healthcare services. 

Getting Reimbursed for Telehealth

One common query most providers have is how they will get reimbursement for telehealth. The answer is that reimbursement rates for telehealth can vary due to laws such as the Pay Parity Laws and whether the qualified healthcare professional is receiving reimbursement from a private payer, Medicaid plan, or Medicare.
For instance, if you live in one of the states that follow the pay parity laws, you will get reimbursement for telehealth similar to the reimbursement you get for in-person visits for the respective service.

Telehealth Billing Guidelines 2023

Telehealth Modifier 93 

Generally, all telehealth sessions, except audio-only sessions, are billed using the modifier 95 or the GT modifier, varying depending on the payer billed for the services. Modifier 95 description includes the CPT code modifier used to bill telehealth services with the place of service code 11, which indicates an office. The place of service code 11 is the same code used when services are rendered in person. 

Modifier 93 is a new CPT code modifier that came into effect at the start of 2022. This modifier describes a real-time interaction between a patient and a qualified healthcare professional located at different sites. It is essential for healthcare providers to bill all audio-only telehealth services using this modifier. 

Temporary Changes In Medicare Telehealth 2023

The changes made in the COVID-19 Public Health Emergency (PHE) were initially meant to be temporary, but the bill passed at the end of last year caused these temporary changes in telehealth billing guidelines to be extended through December 31, 2024.

Two temporary changes that ended back in May included telehealth being provided as an exceptional benefit and Medicare-covered providers not being subject to a federal penalty for using applications that aren’t HIPAA-complaint to communicate with their patients.

The changes that will extended through December 2024 are:

1. Mental health and non-behavioral services can be obtained at any site. Originating site geographic restrictions for these services are waived.
2. Some mental health and non-behavioral services can be delivered through audio-only communication.
3. In-person visits within the first six months of initial non-behavioral and mental health service are also not required. The effective date of this rule was postponed for 151 days after the PHE, which ended in May.
4. Occupational therapists, pathologists, audiologists, and physical therapists are now considered practitioners who can provide care using telehealth.

Permanent Medicare Telehealth Changes 

The focus of the majority of permanent changes made by the CMS (Centers for Medicare and Medicaid) is on mental health care. These include: 

1. RHCs (Rural Health Clinics) and FQHCs (Federally Qualified Healthcare Centers) can be distant site providers for non-behavioral and mental health services. 
2. One of the eligible originating sites for telemedicine services is REH (Rural Emergency Hospital). 
3. Practitioners will no longer receive separate reimbursement for audio-only E/M services. 
4. Virtual Direct Supervision is set to continue only until the end of 2023 and will not remain a permanent feature of Medicare. 
5. Although CMS suggested five new codes to be added permanently to the Medicare Telehealth Services list, only three codes for chronic pain management and prolonged E/M services are made permanent as they are sufficiently similar to other services listed currently on a Category 1 basis. 

FAQs 

How to bill for telemedicine?

To bill for telemedicine, you must first determine the usage and type of telemedicine you offer, check any reimbursement and compliance policies appertaining to your claim, perform accurate coding using modifier 95 or GT depending on the payer, and finally add any CPT codes applicable to the telehealth services rendered. 

Is telehealth covered by insurance in 2023?

Other than Medicare and Medicaid, telemedicine services are covered by most private health insurance plans. However, depending on the state you belong to and the insurance carrier’s policies, reimbursement rates and telehealth coverage may vary. Telehealth services can be rendered through online consultations, audio, or video, so it is best to check in with the payer on what they cover and get a clear idea of the billing requirements. 

Does Medicare cover telehealth?

Typically, telehealth services are covered under Medicare Part B, which has a deductible of $226 in 2023. So, after a patient meets the part B deductible, they only pay 20% of the total Medicare-approved amount to their assigned physician or healthcare provider for the services rendered. 

Medical Coding Audits: What You Need to Know to Stay Compliant

Posted on October 23rd, 2023 / Under Medical Billing / With No Comments

Effective management of healthcare information is incomplete without medical coding. Coding audits are a critical practice performed by a clinical coding auditor to ensure the practice has proper procedures set in place to achieve medical coding compliance. 

Centers for Medicare and Medicaid Services (CMS)and the Office of the Inspector General (OIG) recommend healthcare organizations obtain an unbiased evaluation of their coding practices. This helps providers identify and eliminate errors in medical coding, maintain regulatory compliance, and expedite the reimbursement process. 

Keep reading to learn about how medical coding audits can help you avoid major pitfalls stemming from coding errors. 

Importance of Medical Coding Audits

Coding reviews include examining the medical records of the patients to ensure the provider has selected and entered correct and comprehensive diagnosis and procedure codes. 

A medical records audit generally includes an examination of documentation to ensure it is accurate and complete, reviewing CPT codes, checking the location of patient care, ensuring the modifiers are not absent or incorrect, any absence or presence of any bundling concerns, and a medical coding utilization review. 

Research shows that around 80% of medical bills contain some type of coding and billing errors, costing patients an extravagant amount of money compared to the level of service obtained. Other consequences of not conducting regular coding audits include damage to your practice’s reputation, lost revenue, and compliance risks. 

Medical coding audits can help you uncover any current problematic trends in your practice, including upcoding, outdated coding, unbundling, and downcoding. For instance, multiple issues can affect medical coding accuracy, such as a lack of documentation. A general rule of thumb is medical coders are only able to use the documentation they are provided, so if a healthcare provider records documentation with missing details, it will lead to medical coding errors. Such errors can be identified through regular coding audits. 

Another important reason for organizations to conduct these audits is compliance. Coding and billing practices are required to be in compliance with multiple regulations, including private payer policies, CMS, and OIG regulations. This puts the organization at risk of facing legal repercussions. 

Benefits of Regular Medical Coding Audits for a Healthcare Practice

Reduction in Claim Denial

One common reason why most medical claims get denied at the initial stages is coding errors. Some common issues uncovered during these audits include any wrong diagnosis or procedure codes and insufficient documentation. With proper coding audit policy and procedure, coding errors are minimized. This reduces the risk of medical claims getting denied or rejected by the payer’s insurance provider. 

Revenue Protection

Coding mistakes are one of the major reasons why healthcare practices incur financial loss. For instance, if a claim is under-coded, there are still chances of it getting processed by the payer; this results in practice losing money by getting reimbursed for less than the actual level of services rendered. On the other hand, over-coded claims put the practice at potential risk of a regulatory fine. 

Moreover, coding mistakes discovered during claims processing can cause the payer to deem the claim unpayable. This results in healthcare providers investing extra time and effort into fixing coding mistakes and resubmitting claims. However, with effective medical coding audit software, potential issues can be identified early in the process, helping your organization avoid such revenue loss.

Fraud Reduction

Another reason why periodic medical coding audits are essential is compliance issues and billing fraud. Medical coding audit documents allow organizations to identify any improper billing practices, such as invoicing for services not acquired by the patient or unnecessary services, and help uncover whether such issues were caused through intention or coding error. This allows healthcare organizations to take action and have their staff follow proper billing protocols to eliminate billing fraud. 

Coding Accuracy Improvement

The acceptable coding accuracy rate is 95%, and research shows that medical coding accuracy actually falls way beneath this standard. Coding accuracy impacts your risk judgment and quality of reporting. One major factor that affects coding quality is missing or incorrect documentation, which can easily be identified through coding audits. 

Educating Your Staff

One of the many benefits of coding audits is medical coding training. These audits allow your staff to improve as a team and ensure that your coders have proper training. 

For example, outpatient coding audits will allow your coding team to develop a comprehensive understanding of the CPT system and get informed of the updated regulations. Inpatient coding audits allow coders to recognize changes in AHA (American Hospital Association) guidelines and ICD codes. This way, your coding staff will acquire all the necessary skills required to ensure coding accuracy. 

Preventing Payer Audits:

It is possible for your practice to get flagged for investigation by a payer if coding issues become persistent. The purpose of this investigation is to identify potential coding and billing fraud in practice, which, if found, can lead to financial consequences, including hefty fines. Regular audits can help you avoid any payer investigations for waste, abuse, or billing fraud. 

Internal and External Coding Audits

Generally, a member of the healthcare staff is employed by the organization to conduct an internal coding audit. This could be the auditing team members in large facilities and a clinical coding auditor in smaller organizations. 

Internal coding audits help organizations identify areas of improvement and assess coding accuracy. While it is recommended to conduct regular internal coding audits, the actual frequency of these audits can vary depending on the size of a practice and its available resources. 

External coding audits, on the other hand, are conducted by third-party auditing companies or government companies like OIG and are relatively more objective. These audits can take place biannually or even annually in some organizations. 

External coding audits play a vital role in identifying recurrent coding errors and fraudulent coding practices within the organization. These audits have more value than internal audits as they are performed by an independent party. 

Coding audits, whether external or internal, are essential if your organization wants to maintain medical coding integrity, prevent fraudulent activities, and avoid potential pitfalls.

Latest Changes and Updates In Healthcare Billing Regulations 2023

Posted on October 13th, 2023 / Under Medical Billing / With No Comments

In 2023, similar to previous years, medical billing and coding regulations have been updated. While some of these 2023 medical billing updates are easy to accommodate, others have been reported to need to be more precise and more manageable for healthcare workers.  

Even the smallest updates, like the changes with the QPP (Medicare’s Quality Payment Program), are noteworthy. The coding and billing guidelines are modified each year to elevate the quality of services rendered and patient care. 

It is crucial for your healthcare staff to stay on top of these updates to avoid potential claim denials, lawsuits, delayed reimbursement, and fraud. Read on to learn about the 2023 billing and coding updates and how optimizing them will help your practice.

Updated Medicare Payment Policy

As for updates on physician billing, the original decrease in the conversion factor was a 4.5% reduction to the Medicare Physician’s Fee Schedule payments which was opposed by the majority of physicians. 

So, after groups in the healthcare industry counteracted this decrease in conversion rates by joining hands and asking Congress to lower them, Congress decided to lower the reduction to 2% in 2023, increasing it again to around 3.5% in the coming year, 2024, considering the financial challenges faced by healthcare providers during the pandemic. 

There was also a split-shared visits policy finalized in 2022 by the Centers for Medicare and Medicaid Services(CMS) which was delayed after around 20 physician organizations wrote to CMS, citing their concerns on how the implementation of this policy would negatively impact patient experience and any collaborative care delivery models. According to this policy, in 2024 any shared/split visits are to be billed under the National Provider Identifier (NPI) of the individual who provides a total visit time of more than 50%. For instance, if a physician and an NPP both provide care to the patient, provided that a substantive portion of the physician’s assistant’s time is spent caring for the patient, then the visit will be billed under the NPP’s National Provider Identifier. This leaves the practice with only a Physician Fee Schedule Rate of 85%. Whereas, in 2022, visits shared between a physician and an APP were billed under the NPI of any non-physician practitioner or physician who either provided more than 50% of the total service time or documented the support for medical decision-making, exam, and history.

Modifier JZ 2023

On January 1, 2023, a new modifier known as the Modifier JZ, announced by the Internal Revenue Service (IRS) came into effect. The purpose of this modifier was to streamline the reporting of any services provided in hospital or outpatient settings. 

The JZ Modifier is reported on the same line as the CPT code for a service it is applied to. It offers more clarity for medical claim processing and allows better tracking of services provided in outpatient settings or hospitals. For instance, if a patient received a service or supply at a waived or reduced rate because they are eligible for a government program like Medicare or Medicaid, the JZ Modifier will be applied to the CPT code of the services provided. 

It is one of the critical medical billing updates of 2023 which healthcare providers must familiarize themselves with if they want to receive timely reimbursement.

JG Modifier

CMS proposed that starting from January 1, 2o23 the JG Modifier will be used for identifying the 340B drugs. Hospitals like children’s hospitals, PPS (Prospective Payment System) exempt cancer hospitals, and rural sole community hospitals will continue to use the TB modifier for similar purposes and any other hospitals will be using the JG modifier. 

That is because the JW modifier is one of the modifiers for medical billing required to be applicable when billing the waste of 304B drugs. Other appropriate modifiers in medical coding for 340B drugs like the JG modifier should be used by eligible healthcare facilities.

Codes for Biosimilars

In the 2023 CPT/HCPCS code set release, CMS has included new drug code biosimilars which are FDA-approved medications. These medications are similar to other biological drugs in dosage, usage, efficacy, and potential side effects but they cost relatively less. 

CMS is reported to reimburse the biosimilars with an ASP equal to or less than ASP 8% which is the reference biological price. This is done to drive down drug costs and boost the production of biosimilars. 

Considering that the reference biological reimbursement is APS 6%, the 2% increase for biosimilar drugs is a step forward to a greater impact on patient care. This increase started back in October 2022 and is set to continue for up to five years.

FAQs

1. What are the changes in CPT coding for 2023?

CPT codes have gone through multiple changes in 2023, including: 

• 93 revised codes and 75 CPT codes were deleted. 
• Changes to the evaluation and management (E/M) codes and Covid-19 vaccination codes. 
• Except for anesthesia, all departments of the CPT 2023 code set were recorded to have coding and guideline changes. 

2. What are the ICD 10 changes for 2023?

The ICD-10 changes for 2023 include several terms being modified, 251 codes being deleted, and 36 ICD-10 codes being converted into parent codes. There are around 1176 new billable ICD-10 codes in 2023, among which some major changes are recorded in endometriosis, motorcycle accidents, head injuries, maternal care for fetal disorders, and dementia. 

3. Can you bill for a PA under the supervising physician?

It can depend on payer requirements. For instance, some payers can enroll or credential PAs while others can require any services rendered by the PA to be billed under the National Provider Identifier (NPI) of their supervising physician. 

4. How many CPT codes are there in 2023?

The CPT code set for 2023 has 10,696 codes, describing services and medical procedures that are available to patients. This set includes at least 93 revisions, 75 deleted codes, and the addition of 225 new codes. The CPT code set will further evolve with growing innovation. 

What Is Claim Adjudication? A Critical Phrase In Medical Billing

Posted on October 10th, 2023 / Under Medical Billing / With No Comments

The process of submitting a patient’s claim to their insurance provider and receiving reimbursement after the provider performs a manual review of it may appear straightforward, but it’s not that simple.

There’s significant information, billing codes, clinical data, and much more involved in the claims submission process that makes it complicated. Every medical claim, whether it gets accepted or denied, undergoes adjudication once received by the insurance provider.

Although, as a healthcare professional, you might not have much control over how the adjudication process unfolds after claim submissions, you can keep reading to gain insights that increase your chances of getting quick reimbursement for the next claim submitted by your organization.

Here is what you should know about adjudication in medical billing.

Adjudication Process In Medical Billing

The claim adjudication process in medical billing is when the insurance payer reviews a claim submitted by the healthcare organization and determines the extent of their responsibility to pay for the medical services by comparing the claim to any benefit requirements, reference files, or coverage.

Doing so enables them to adjust the amount they will pay to the healthcare provider if required. The adjudication process could also lead to a significant reduction of the billed amount or denial of the claim altogether. For example, if a claim is invalid or contains billing and coding errors, the payer has the authority to deny paying for it. The overall adjudication process involves five steps:

1.     The Initial Processing Review

Did you know that the majority of medical claims submitted to insurance companies are denied at the initial stage of the adjudication process? The reason behind this is claims are reviewed initially to detect simple errors including, grammatical mistakes, spelling errors, incorrect place or date of service code, invalid diagnosis code, and incorrect subscriber identification number. At this stage, the healthcare provider can recheck a denied claim, make necessary amendments, and resubmit it. While denials may not prevent the provider from resubmitting the claim, it does cost the organization resources and time. This is why many healthcare professionals now use all-inclusive medical billing services to minimize the risk of simple errors in claims.

2.     Mass Adjudication or Automated Review

The automated review of a claim is more detailed and complicated because the claim is checked against the payer’s payment policies, including any copayments, fee schedules, relevant contracts, and service groups. Patient eligibility, duplicate claims, unbundling, down coding, pre-certification issues, expired filing deadlines, and issues with the level of patient care are identified at this stage of the adjudication process.

3.     Manual Review

If a claim is tagged in edits and does not pass the automated review stage, it will be pending for the manual review, which is done by a medical claim examiner. At this stage, the medical claim examiner requests medical records to manually compare them with the claim. In some cases, a nurse or physician may also be involved, typically if there is an unlisted procedure.

4.     Post Adjudication Process

In some cases, even if claims do not get rejected throughout the adjudication process, the insurance payer may conduct secondary auditing of your claims. This ensures that the claims are in compliance with any state or federal regulations, coding combinations, editing, and other guidelines.

5.     Payment Determination

At this stage of the process, the payer determines whether the claim is reimbursable or not. They can also decide to downcode the billed amount to an appropriate level if it is too high and does not match the level of service provided or the final diagnosis.

6.     Payment

The payment provided by the payer after adjudicating a claim is either called the explanation of payment or remittance advice. That is because other than the funds, the payer also provides the healthcare facility with reasons for denial, reasons for the payment itself and any reduction, and details of uncovered charges.

FAQs

What Is Adjudication In Healthcare?

Adjudication in healthcare is the process of insurance payers reviewing claims submitted by healthcare providers and comparing these claims with coverage requirements and other contracts to either pay or deny them. Some insurance providers process medical claims through software for adjudication purposes. This is also known as auto-adjudication.

How Does Claim Adjudication Differ from Claim Submission?

To get reimbursement for the services provided, healthcare professionals submit claims to the insurance providers of the patients. The process of gathering patient information and clinical data, coding the diagnosis and services rendered, and billing the insurance provider is known as claim submission. Whereas claim adjudication is the review of the medical claim performed by the insurance company through which it determines whether a claim is reimbursable or not.

How Long Does the Claim Adjudication Process Typically Take?

While there can be distinct circumstances surrounding every medical claim submitted, and each insurance payer’s adjudication process may also differ, typically a claim adjudication process can take up to two weeks before the insurance payer makes a decision to pay the claim in full, down code the billed amount, or deny the claim.

What Is the Impact of Claim Adjudication On Healthcare Providers?

Healthcare organizations utilize the data gathered from claim adjudication processes to accelerate their go-to marketing strategy and trace referral patterns. Claim adjudication system in medical billing also helps ensure that the medical claims are valid and accurate.

What are the Five Steps In the Adjudication Process?

The adjudication process in medical billing includes five steps: the initial processing review, the automated review where the claim is compared with policy documentation, a manual review performed by a medical claim examiner, payment determination, and payment.

How Do Errors In Medical Billing Affect Claim Adjudication?

Errors in medical billing can be identified in the initial stage of the process or after the automated or manual review is conducted, and these errors can cause payment delays, claim denials, and even lead to legal liabilities. Some common medical billing errors that affect adjudication include upcoding, downcoding, lack of documentation, and incorrect selection of the level of services rendered.