By Carol Hoppe, CPC, CCS-P, CPC-II
I know it's frustrating for many right now, figuring out denials and payments for telehealth as payers are starting to process claims and Medicare made another change in the rules. Here are the latest updates.
Medicare is paying for phone calls at a higher rate
The latest Interim Final Rule
states this regarding payment rates: "Specifically, we are crosswalking CPT codes 99212, 99213, and 99214 to 99441, 99442, and 99443 respectively."
For those of you who billed the 99441-99443 codes at lower rates than you would a 99212-99214, you will need to do a Clerical Error Reopening on the portal and change the price. Make sure you used POS 11 and no modifier with these codes. Once you complete the CER, Medicare will reprocess the claim and pay the difference.
Telephone Evaluation, Management/Assessment and Management Services, and Behavioral Health and Education Services
Anthem HIP and Medicaid
- A broad range of clinicians, including physicians, can now provide certain services by telephone to their patients.
- Medicare payment for the telephone evaluation and management visits (CPT codes 99441-99443) is equivalent to the Medicare payment for office/outpatient visits with established patients effective March 1, 2020.
- When clinicians are furnishing an evaluation and management (E/M) service that would otherwise be reported as an in-person or telehealth visit, using audio-only technology, practitioners may bill using these telephone E/M codes provided that it is appropriate to furnish the service using audio-only technology and all of the required elements in the applicable telephone E/M code (99441-99443) description are met.
- Using new waiver authority, CMS is also allowing many behavioral health and education services to be furnished via telehealth using audio-only communications. Here, the full list of telehealth services notes which services are eligible to be furnished via audio-only technology, including the telephone evaluation and management visits.
I know many of you are getting denials and lower reimbursement for Anthem HIP and Medicaid. Here's what I understand from this week’s Medicaid live webinar:
- For Anthem HIP claims, Anthem has to apply Medicare payment rates, but that does not necessarily mean Medicare methodology.
- Codes 99441-99443 are not covered for HIP or Medicaid plans; they are only covered for Medicare crossover claims.
- The state covers telemedicine via audio only or audio/video with codes 99201-99215.<
- You must follow the guidelines identified in the state’s bulletins and banners regarding telemedicine. The POS will depend on the procedure code and location. The Medicaid guidelines for POS and modifiers are identified on my Indiana Decision Tree.
- Modifier 95 can only go with POS 02, or your claim will deny.
My understanding here is that Anthem is only going to pay for E/M codes 99201-99215 for both audio-video and audio-only with POS 02 and modifier 95. However, for Anthem HIP, they will only pay the facility rate based on Medicare guidelines for POS 02.