CMS Telehealth Coding Presents New Challenges
As our recent article on Telehealth indicated, the Centers for Medicare and Medicaid Services (CMS) officially expanded its payment protocol to cover Medicare telehealth services in March of 2020. This meant that providers had greater flexibility in providing treatment and visits, with Medicare covering treatments that they previously would not have. This led to a surge in the use of telehealth, with utilization at levels 38 times higher compared to pre-PHE. In April of 2020 alone, around 44% of Medicare primary visits were done via telehealth.
Other changes followed in both 2020 and 2021. In October of 2020, CMS added 11 procedures to the Medicare telehealth reimbursement list, including cardiac rehab, pulmonary rehab, and electronic analysis of implanted neurostimulator pulse generator/transmitter. Then, in March of 2021, CMS removed four mistakenly-added telehealth codes from the Medicare Physician Free Schedule (MPFS). Finally, in November of 2021, CMS extended certain telehealth codes, as well as updating its telehealth guidelines for mental services and virtual check-ins. This expansion of telehealth rules potentially indicates that telehealth is here to stay.
The Challenges of Telehealth Coding
However, there have been some problems as well. For instance, a debate has recently flared up over how billing should be done for “audio-only visits”; this mainly refers to doctors making follow-up phone calls to patients. Currently, Medicare reimburses short phone calls at a rate of $14 for 5-10 minute calls. The rate is $27 for 11-20 minute calls. These rates are currently set to expire at the end of the PHE. Doctors want Medicare to permanently reimburse for these visits at the same rate as in-person visits. Practitioners argue that this is necessary to maintain high-quality service during the pandemic. Insurers oppose this, claiming that this billing parity would lead to over-reimbursement, with unnecessary and overly-long follow-up calls to patients. Many analysts say the solution is likely somewhere in the middle.
Besides debates over coding, there have also been reports of outright telehealth fraud, as discussed in an article for the National Law Review. For example, pre-pandemic guidelines required a face-to-face examination with a physician before ordering durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for a patient. This also meant the physician would bill the appropriate code. But due to new regulations related to the PHE, CMS had modified those requirements, raising questions about how government agencies will spot and prevent fraudulent DMEPOS claims. The story is similar in other situations, such as genetic laboratory tests. Agencies had previously used the lack of coding and no contact with an in-person provider as an indicator of fraud; such a rule of thumb is no longer applicable due to loosened telehealth rules. Agencies will need to adapt their thinking in order to root out new telemedicine scams.
Contact YES for Additional Information
While there’s still some uncertainty surrounding telehealth billing, there’s little doubt that telehealth will continue to be a significant component of healthcare services. That’s why it’s so important to understand all the relevant telehealth codes. You can find more resources on telehealth coding here. If your firm needs help with telehealth coding, feel free to reach out to YES HIM Consulting!