It’s been widely reported that the CMS has lifted the restrictions on telehealth services. As lockdowns expand and the use of telemedicine surges for both COVID-19 and non-COVID-19 cases, the AMA is creating new codes and processes to address the unique situations. Factors including place of service, place of testing, provider types (physicians and non physicians), diagnosis, E/M and telehealth codes will impact denials and billing issues.
As of 2 April, here is a short list of scenarios that health insurance brokers should expect that may cause denials and general confusion at the billing level:
Telehealth visit for a COVID-19 diagnosed patient
Place of Service: Telehealth
Who is performing: Physician/QHP
Typical time: 10 min, 15 min, 25 min, 40 min
Telehealth visit for a non-COVID patient
Place of Service: Telehealth
Who is performing: Physician/QHP
Typical time: 10 min, 15 min, 25 min, 40 min
Patient with COVID-19 receives virtual check-in or on-line visits via portal/email (not related to E/M visit) or telephone call from qualified nonphysician
Place of Service: Physician office
Who is performing: Physician/QHP
Typical time: 5-10 min, 11-20 min, 21-30 min
Virtual check in or on-line visit for a non-COVID patient
Place of Service: Physician or normal office location
Who is performing: Physician/QHP
Typical time: 5-10 min, 11-20 min, 21-30 min
Patient comes to office for an Evaluation and Management (E/M) visit, is tested for COVID-19 during the visit
Place of Service: Physician Office
Swab collected: Clinical Staff (RM/LPN/MA)
Test Performed: Laboratory (office, hospital, independent lab)
Physician orders remote physiologic monitoring following patient quarantined at home after receiving COVID-19 diagnosis
Place of Service: Physician office
Who is performing: Physician/QHP/Clinical staff
Procedure: Remote physiologic monitoring; first 20 mins
Patient comes to office for E/M visit re: COVID-19 and is directed to a testing site
Place of Service: Physician Office
Swab collected: Testing Site
Test Performed: Laboratory (office, hospital, independent lab)
Patient received telehealth visit re: COVID-19, and is directed to come to physician office for testing
Place of Service: Telehealth
Swab collected: Clinical Staff (RM/LPN/MA)
Test Performed: Laboratory (office, hospital, independent lab)
Patient received telehealth visit re: COVID-19, and is directed to an unaffiliated testing site
Place of Service: Telehealth
Swab collected: Testing Site
Test Performed: Laboratory (office, hospital, independent lab)
Patient receives virtual check-in/online visit regarding COVID-19 (not related to an E/M visit) and is directed to come to physician office for testing
Place of Service: Physician Office
Swab collected: Clinical Staff (RM/LPN/MA)
Test Performed: Laboratory (office, hospital, independent lab)
Patient receives virtual check-in/online visit regarding COVID-19 (not related to an E/M visit) and is directed to come to unaffiliated testing site
Place of Service: Physician Office
Swab collected: Testing Site
Test Performed: Laboratory (office, hospital, independent lab)
*Note the payment policies of insurance carriers will also affect denials.
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