Rethinking Your Approach to Virtual Reimbursement: 4 Things to Consider

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Healthcare experts are saying telehealth is here to stay, with Medicare indicating it may permanently expand telehealth services for seniors. There have also been a projected one billion visits in 2020 alone. But navigating reimbursement for telehealth and other virtual care can be tricky. As a result, some revenue cycle teams have found they need extra guidance and training.

Across the nation, Medicare, Medicaid and commercial payers have increased telehealth reimbursement for approved services in response to the need for virtual care during the pandemic. Depending on the payer, some telehealth services are paid at the same rate as an in-person visit, ensuring payment parity.

But not all services that are provided virtually are covered by payers. Additionally, determining the difference between a video visit and an e-visit—and the variations in reimbursement for each type of virtual visit—is a nuance that many billing staff had not encountered before COVID-19.

How can revenue cycle leaders support the right reimbursement for virtual care? Here are four things to consider.

Ramp up internal resources for educating staff. The number of telehealth waivers issued by the Centers for Medicare & Medicaid Services (CMS) alone—from expanding the types of professionals who can offer telehealth services to enabling providers to offer services via audio-only communication—would be challenging for revenue cycle teams to keep up with under the best of circumstances. The sudden shift to a remote environment added an extra layer of difficulty in navigating telehealth reimbursement changes. Some revenue cycle teams are still mired in the complexities.

One way revenue cycle leaders can better position their teams to process telehealth and e-visit claims correctly: Establish an internal expert for telehealth and e-visit billing. This team member should:

  • Dig deep into telehealth and e-visit denials to determine the root causes of rejections
  • Review common errors in telehealth and e-visit charge capture and claim processing with staff and share best practices
  • Stay up to date on reimbursement changes for virtual care and convey these changes to staff
  • Work with clinicians to improve charge capture for telehealth and e-visits, where needed

Another best practice: Build in weekly education around billing for virtual care. This could be a standing agenda item during revenue cycle team meetings or remote education via the hospital’s intranet.

Understand what is covered—and what isn’t. Did you know that virtual lactation support typically isn’t covered by insurance plans? Neither are certain intensive therapies—both physical and occupational. And while more payers are expanding telehealth services to audiology and speech-language pathology, not all of them are.

Here are four codes that typically are rejected when care is delivered virtually:

  • 96150 – Assess LTH/BEHAVE, INIT
  • 96151 – Assess HLTH/BEHAVE, SUBSEQ
  • 90640 – Brief Follow-Up Consultation
  • 90887 – Consultation with Family

Know the difference between types of virtual care. Telehealth visits are provided via video or can be auditory-only. E-visits, on the other hand, take place via a secure messaging platform for patient-initiated evaluation and management (E/M) services. Most providers that have high telehealth volumes do not have high e-visit volumes; the reverse also is true.

For most providers, the challenge with e-visits not only lies in understanding what constitutes an e-visit, but also when to bill for one. For instance, a physician may not realize that a medical consultation delivered via email is eligible for reimbursement under some insurance plans. And while e-visit reimbursement usually is reserved for established patients, some payers have made exceptions during the pandemic, when in-person visits were limited to the sickest patients.

Although reimbursement for e-visits is low—about $11 to $33 per visit—these dollars can add up quickly. For example, Michigan Medicine conducted 2,472 e-visits in March alone; a year earlier, just 369 e-visits were performed. Meanwhile, Lehigh Valley Health Network in Pennsylvania recorded 3,300 e-visits in March and April; formerly, the health system averaged 150 e-visits per day.

This makes it doubly critical that clinicians and revenue cycle staff understand the nuances of e-visit reimbursement, especially as some consumers express concern over returning to a healthcare setting following the pandemic and switch to e-visits.

Education around e-visits for physicians, clinicians and revenue cycle staff is key. Teach key stakeholders what constitutes an e-visit and the types of documentation required for reimbursement. Then, hone in on the finer points of billing for e-visits with revenue cycle staff, with a focus on the following e-visit codes:

CPTs:

  • 99421 – OL DIG E/M SVC 5-10 MIN
  • 99422 – OL DIG E/M SVC 11-20 MIN
  • 99423 – OL DIG E/M SVC 21+ MIN

HCPCS:

  • G2061 – Qual NonMD Est PT 5-10 MIN
  • G2062 – Qual NonMD Est PT 11-20 MIN
  • G2063 – Qual NonMD Est PT 21+ MIN

Don’t forget remote patient monitoring. During COVID-19, Medicare allows physicians to be reimbursed for remote patient monitoring services offered to new and established patients. This applies to patients who have acute or chronic conditions and—under the Medicare waiver—for patients with just one disease.

CPT codes for remote patient monitoring include:

  • CPT Code 99453: Remote monitoring of physiologic parameter(s), initial; set-up and patient education on use of equipment
  • CPT Code 99454: Device(s) supply with daily recording(s) or programmed alert(s) transmission: Every 30 days
  • CPT Code 99457: Remote physiologic monitoring treatment management services, performed by a clinical staff/physician/other qualified healthcare professional time in a calendar month, requiring interactive communication with the patient/caregiver during the month: First 20 minutes
  • CPT Code 99458: Each additional 20 minutes

These codes require general supervision by a physician or a nurse practitioner.

The Right Path for Telemedicine Reimbursement

Although a recent report suggests use of telehealth during the COVID-19 pandemic may have peaked, it’s clear that consumers’ appetite for telehealth remains strong. As healthcare revenue cycle teams look for opportunities to strengthen their organization’s financial health following the pandemic, a focus on telemedicine reimbursement will be critical to short- and long-term success.

ABOUT THE AUTHOR

As director of product management, Lori Brocato is responsible for planning and executing around The SSI Group’s product strategies. Before joining SSI, Lori held positions at Cotiviti, NextGen Healthcare and HealthPort. Lori earned a degree in accounting from Tampa College.

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