News to Note – June 2020

• Changes to CMS rules involving telehealth continue to evolve with increased payment for telephone calls and allowing hospitals which employ doctors to bill for the facility fee on telehealth visits.  Now that the facility fee can be billed, payment for employed doctors is about equal to independent doctors.  For physicians and therapists in private practice, if they provide a telehealth service with audio and video they can bill as if in-person with the 95 modifier.  For employed physicians and therapists, they can designate the patient’s home as a provider-based clinic to allow billing of services provided there. Yep, if the patient is sitting at home watching Jerry Springer, they are in their house. If they are on their smart phone having a telehealth visit with their physician or using Zoom on their laptop to do physical therapy exercises for their knee arthritis, they are actually in a hospital clinic. Be aware – the guidance from CMS on the code to charge for the facility fee seems to change weekly between Q3014 and G0463.
• There is equal confusion on billing for therapy provided to a patient in their home via Facetime or Zoom when the home is designated as a provider-based clinic and the therapist is employed by the hospital. All that hospitals really want to know is, what place of service and what modifiers do they use?  CMS says you do not use the 95 or GT modifier because this is not telehealth, it is remote provision of services.  If a doctor uses FaceTime, it’s telehealth.  If a therapist uses FaceTime, it’s not. What they need is a coder who has produced a claim to be at the CMS town halls to answer questions.  Currently, it seems if you bill as if the patient was receiving the service face-to-face, you use place of service 19 and you use the PN or PO modifier that you would have used if the patient was being seen in person.  As above, the regulations change weekly. Be glad you are not a coder or biller!
• One of the most confusing parts of this pandemic is the proper use of modifiers, condition codes, and place of service coding.  It is made much more difficult because each payer has their own rules on how they should be used. For physician visits for telehealth, most want the place of service as if the patient was seen in person, but some plans want place of service 02. The DR condition code was designated by the National Uniform Billing Committee to be used on institutional claims that require special handling of the claim. For some payers, they want that on every claim for every COVID-19 patient – perhaps so they can identify when the patient’s copayment and deductible should be covered by the payer. But, shouldn’t the presence of the COVID-19 ICD-10 code tell them that? For Medicare claims, they only want it on the claim when a formal waiver was used so a COVID-19 patient who was admitted as inpatient and stayed five days doesn’t need a DR but a Skilled Nursing Facility patient admitted without a three-day stay does need one. What about the CR modifier which is used on Part B claims like physician claims?  CMS says physicians should use the CR if they provide hospital care at a temporary hospital location. Treating COVID-19 patients is a challenge.  Properly getting paid for that care is going to be a whole different challenge.
• The Health Resources & Services Administration (HRSA) program to reimburse providers for care for the uninsured is going to allow all provider types to submit claims for care to COVID-19 patients who have no insurance.  The program is being administered by United Healthcare.  Once you register and the portal opens, you are supposed to be eligible for submitting claims.  But, it’s not that easy. First, the rules say COVID-19 must be the primary diagnosis.  If it is not, the claim is not eligible for payment except for pregnancy.  While most hospitalized patients will have COVID-19 as the principal diagnosis, not all will.  If they present with sepsis, COVID-19 is not the primary diagnosis and the claim will not be eligible, per the rules.  If a physician is consulted for anemia or renal failure in a COVID-19 patient, that also won’t be eligible for reimbursement because the primary diagnosis is not COVID-19.  According to Valerie Rinkle, the regulatory specialist for the National Association of Health Care Revenue Integrity, HRSA is not a HIPAA-covered entity.  So, hospitals can violate coding rules and re-sequence the codes on those claims to match the HRSA requirements. It’s appropriate to put COVID-19 first, then a diagnosis like sepsis. All claims processed are final; no adjustments, no appeals, and no balance billing the patient.  For certain, there will be more developments on this front.
• Information learned from CMS town halls continues to be expansive.  From finessing the regulations to allow telehealth via smartphone, to allowing a patient’s home to be considered a hospital outpatient clinic for providing therapy services, and many other things, they truly are making a huge effort but still need more input from clinicians and coders.  For example, a hospitalist asked if she should put the CS modifier on all of her observation visit codes when she cares for a COVID-19 patient. She was told yes, but the Families First Act limits its use to visits where the COVID-19 test was either ordered or performed. Once a hospitalist gets called to see the patient, the test has already been done by the Emergency Department doctor, so why would the modifier go on the hospitalist’s claims? We also have no idea what edits will be in place to determine if the CS modifier was used properly. What if she does use it? Will the claim get paid at 100%? Wouldn’t that be easy pickings for the RAC later, to look for patients where more than one provider used a CS modifier?  It appears CMS staff may not understand who takes care of patients at each step in the hospital and what care they provide.
• In news from a Managed Medicaid plan in Michigan:  A patient was discharged from a hospital after an inpatient admission unrelated to COVID-19. Three days later, they presented to another, completely unaffiliated hospital with the same problem that led to their first admission. The patient was evaluated and determined to require inpatient admission. The patient remained hospitalized for several days. The payer contacted the second hospital and informed them that they were denying payment for their admission because the discharge from the first hospital was premature and so the second admission could have been avoided. Now that in itself is outrageous, but the payer representative also said that Medicare rules allow this, citing a clause that allows the Quality Improvement Organization (QIO) to deny payment for repeat admissions when it is appropriate.  So, a Medicare rule that applies to the QIOs can be used by a Medicaid managed care plan to deny a repeat admission when that facility had absolutely no control over the care at the first hospital?  That is just so very, very wrong.  Push back if you encounter a similar situation.