Category Archives: Medical Billing

Telehealth webinar

Sorry for the late notice. Today 05/30/18 and Monday 06/04/18 I am hosting four 30 minute webinars on how to incorporate telehealth into your practice. 

Email newgenerationbilling@gmail.com or call me at (909) 610-9524 if you want to sign up. 

These four webinars will be focused on California, but if my providers in other states are interested, I can host webinars focusing on your state. Just let me know. 

Have a great day, guys!

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Filed under Medical Billing, Telehealth

How to get a fat check for your obesity counseling.

Full disclosure, I am not that funny. That title was suggested to me and it was too good not to use.

Moving on.

Insurances have come a long way in the last 15 years. Even the best PPO plans in 2003 wouldn’t pay for “weight loss” even for morbidly obese patients. Patients had to jump through hoops to get mental health services and your insurance probably still laughs at you if you need chiropractic or acupuncture. 

However, insurances have started to realize that weight management, mental health, and pain management without addiction are vital to a patient’s overall health. Many insurances have incentivized obesity reduction , both with fee for service payments, and bonuses, as part of a focus on a patient’s health, rather than their illness. 

Insurances differ, though, on HOW they are going to pay for obesity counseling. Many offices end up not receiving their proper reimbursement because each insurance company wants the service reported a different way. This guide will help you get paid for your obesity counseling in addition to your regular office visit. 

All insurances will only pay for obesity counseling if the patient has a BMI over 30. If the patient’s BMI is under that, but they are still overweight, by all means please continue to help them bring their weight to a healthy level, but you won’t be reimbursed separately. Also, see the disclaimer at the bottom of the article please. 

Medicare and Medi-Cal – Use the Z-code for BMI as the primary diagnosis on the line item and use CPT code G0447. Put a 25 modifier on your office visit.  

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32                                                                  G0447

I am not sure if the Medicaid programs in other states will pay for obesity counseling, I know they will in California. 

Blue Cross, Blue Shield, Aetna, Cigna, Health Net PPO/MC/EPO plans – Use the Z-code for BMI as the primary diagnosis on the line item and use CPT code 99401. Put a 25 modifier on your office visit. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32                                                                  99401

Not all Health Net plans or BlueCross Blue Shield plans pay for obesity counseling, but most of them are coming out of the dark ages. 

United HealthCare Commercial PPO/MC – Use the E-Code for morbid obesity as the primary diagnosis on the line item. Use the Z-code for BMI as the secondary diagnosis on the line item and use CPT code 99401. Put a 25 modifier on your office visit. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                E66.01          Z68.32                                              99401

United HealthCare Medicare Advantage plan – Use the E-Code for morbid obesity as the primary diagnosis on the line item. Use the Z-code for BMI as the secondary diagnosis on the line item and use CPT code G0447. Put a 25 modifier on your office visit and a 59 modifier on the G0447.

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                E66.01          Z68.32                                              G0447           59

HMO Plans – It’s capped. Do whatever you want. If you have a fee for service contract, the 99401 usually gets paid a little more than the G0447, so I suggest you use the format for the regular commercial plans. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32          E66.01                                             99401

Some senior plans will give providers a bonus for treating patients with more severe diagnosis. Not a fee for service bonus, but a quarterly bonus. So, also add the appropriate E-code to help your doctor increase their score. 

~~~~

Here is the disclaimer. One of my favorite things to remind you is that in the billing world, the rules change every 10 minutes. So, if you are reading this in 2020, there may be different regulations to follow. Email me. 

Also, if you are billing the obesity counseling with any other type of counseling, you will probably have to be quite liberal with the 59 modifiers in order to get each line item paid separately. In fact, if my doctor does an obesity counseling and a smoking cessation counseling, I will switch the 99401 to a G0447 for the commercial plans (UHC is the exception) so it doesn’t get bundled. Blue Cross requires a 25 modifier on the G0447 if you bill it that way. 

If you want me to help you by reviewing a couple of your claims for the correct coding, I will be happy to do that. 

As always, call (909) 610-9524 or email newgenerationbilling@gmail.com with questions or to schedule an online training seminar. 

 

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Filed under Medical Billing, Modifiers, Obesity Counseling, Office Visit

Telehealth

This post will teach you how to incorporate video conferencing programs into your practice. And to get paid for those visits. If you hate my intros then skip down to the fourth paragraph. It happens, I’m not mad, you are busy people.

Insurances WANT to pay for telehealth visits. Video conferencing for medical care helps keep costs down by keeping people out of urgent cares and emergency rooms. Two of my providers recently started using Skype and Facetime to see a couple of their patients. The psych was seeing a patient who was living in another country and the Internal Med was treating a patient who was recently left without transportation and has a condition that needs careful management. After the patient missed two appointments in a row,  the Internal Med decided it was better to have a Facetime visit than to for the patient to run out of medicine that causes severe issues if you stop taking it suddenly. Both doctors actually assumed they wouldn’t get paid and didn’t give me the superbills for those visits.  That was fun. 

It took several hours of research and some new terminology to get the whole story on telehealth/telemedicine. Good news is, most of you can get paid for telehealth visits from most insurances. Medicare is the exception and will only pay for telehealth visits when a patient is either outside of a metropolitan statistical area or in a rural health professional shortage area. If your patients fall into those categories you can bill regular E&M codes. Here is the Medicare guide on telehealth if you would like more detailed information. 

The laws regulating telehealth also vary by state. There are no states that specifically  disallow using video conferencing to treat your patients, but some states restrict required reimbursement to specific specialists, some states require written consent, some need you to be licensed in the state the patient is being seen in as well as the state you normally practice in, and some states have no laws regarding telehealth at all. Below is a list of the basic information for each state. Press CTL + F and type your state in the search box that pops up to jump right to the information relevant to you. At the end of the article, I’ll discuss some of the reasoning behind the various requirements and what you can do if you don’t like your states telehealth laws.

Alamaba – No laws in place, but Medicaid and private insurances will cover telehealth. For commercial insurance, check the benefits of the patient’s plan. Most resources regarding Alabama regulations refer to it as telemedicine. Because there is no law, there is no mandate for parity in reimbursement, so it would be worth your while to call the insurances and check the fee schedule for those visits. In most other states, telehealth visits are billed with regular E&M codes. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill.

Alaska – Telehealth regulations revised 2017. The state requires private insurances to pay for telehealth for mental health as of 2016, and Medicaid has a very comprehensive reimbursement policy for remote visits. Use modifier GT for live videochats. Check benefits on the patient’s plan for specialties other than mental health.

Arizona – The law requires private insurances to pay for telehealth, but only for a limited number of conditions (trauma, burn, cardiology, infectious diseases, mental health disorders, neurological diseases including strokes, dermatology, pulmonology). Telehealth for other conditions may be covered at the discretion of the insurance provider.

Arkansas – Arkansas makes telemedicine very easy. And the regulations are incredibly easy to find and easy to read. The rules fall under Regulation 38. Please check out the link. Basically, the doctor is required to keep the same standard of care, keep detailed records, and cannot prescribe controlled substances for new patients. There are no specific requirements about written or verbal consent for the service.

California – Telehealth regulations in California have been evolving quickly. The most current law, AB 809, was passed in 2015, and states that the standard of care is the same whether the patient is seen in-person, through telehealth or other methods of electronically enabled health care. Physicians need not reside in California, as long as they have a valid, current California license. California providers are required to obtain and document verbal or written consent for the visits. California also very specifically states that only video conferencing counts as telehealth and specifies that only “real-time two-way communication” (or live video) will qualify. Controlled substances may only be prescribed if the patient has had a previous in person visit. The CA Medical Board website has a very succinct guide.

Colorado – House Bill 1029 governs telemedicine reimbursements in Colorado and, as with most things, Colorado is quite progressive. Insurers are required to reimburse providers for telehealth services. Doctors are not required to have an in-person visit before establishing care via video conferencing, there are no rules regarding “originating sites”, but providers do need to be licensed in the state of Colorado. Informed consent is required to be obtained and documented in the note. Medical marijuana is not allowed to be prescribed or even recommended during a telehealth visit.

Connecticut – SB-467 took effect on 01/01/16 and regulates telehealth in Connecticut. Insurers are required to reimburse providers for telemedicine the same way they reimburse for in office visits. Connecticut also takes a very broad view of telehealth and allows providers to use “store and forward” video to provide services to a patient, unlike most other states with telehealth laws that restrict visits to live video. Consent is required to be obtained and documented in the medical record. Insurances can also authorize telehealth visits the same way they authorize in person visits. The text of SB-467 is a bit of a slog, but is fairly straightforward and worth a read if you want more specific information.

Delaware – HB-69 unanimously passed in 2015, and while it allows telehealth, does have some specific restrictions on providers and patients. The regulation has quite a few factors required to “create a valid doctor-patient relationship,” and providers are only allowed to prescribe once that relationship has been established. This article on http://www.healthcarelawtoday.com was very helpful. Insurers are required to cover telehealth the same way they do regular office visits, only for “real-time two-way communication”.

Florida – Florida legislature has not passed any laws regulating telehealth, but the state medical board has issues rules 64B8-9.0141  and 64B15-14.081. Florida does not specify what type of video conferencing counts as telemedicine, but they do state that telephone, fax, and online questionnaires do not qualify. Providers are not allowed to prescribe controlled substances with a telehealth visit. Because Florida does not have a law, insurances are not REQUIRED to pay for telehealth services. Many of them allow these visits and want patients and providers to use them, as it lowers costs, but it will depend on the patient’s plan. Call and check the benefits for each patient before providing services.

Georgia – The Georgia Telemedicine Law went into effect in 2006 and insurers are required to cover telehealth visits the same way they cover in person visits. Patients are required to have at least one in person visit annually in order to be eligible for visits via video conferencing, and an in person exam must be done prior to any telehealth services. Georgia Medicaid requires providers to obtain written consent, but verbal consent is acceptable for other insurers.  Providers are also required to give the patient clear instructions on follow up in the event a patient needs emergency care and cannot prescribe controlled substances. The Georgia Medical Board put out this article with updated regulations in 2014.

Hawaii –  Senate Bill 2395 was passed in Hawaii in 2016 and went into effect on 01/01/17 and requires Medicaid and commercial insurances to pay for telehealth visits as they would in person visits. The Hawaii bill is unique in that it also includes requirements for malpractice coverage regarding telehealth. Your malpractice insurance would be able to help you with the specifics of your coverage. A face to face visit is not required to provide telehealth to a patient and there are no longer any geographic restrictions to providing remote services to Medicaid patients.

Idaho – Idaho regulates telehealth with HB189 also known as the Idaho Telehealth Access Act. A provider does not have to see a patient in the office in order to provide telehealth services and can prescribe with two restrictions. Controlled substances are limited to in person visits and no drug may be prescribed through telehealth services for the purpose of causing an abortion. Idaho Medicaid will cover limited physician-provided mental and behavioral health services, as well as some services for children with developmental disabilities. Providers are required to obtain either verbal or written consent and document that properly in the note. Both live video and “store and forward” video are acceptable for telehealth in Idaho. According to this Idaho Medicaid Policy telehealth services are covered for mental health and primary care.

Illinois –  SB1811 governs provider-patient relationships regarding telehealth in Illinois and was recently passed in 2017. Unlike other states, this law is simply a series of definitions. It outlines a providers responsibility in terms of establishing a doctor-patient relationship and has no requirement that insurers cover telehealth visits. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. There are no laws regarding consent or prescribing, but it is always safe to document consent and adhere to the same standard of care for telemedicine as you would for in person visits. 

Indiana – Insurers in Indiana are required to cover telehealth visits, however the law does not mandate parity in reimbursement, so it would be worth your while to call the insurances and check the fee schedule for those visits. In most other states, telehealth visits are billed with regular E&M codes. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. This article from healthcarelawtoday.com breaks down the providers responsibilities very well. The doctor has eight steps to take to establish a doctor-patient relationship and some specific restrictions on prescribing.

Iowa – The Iowa Board of Medicine has issued the following rules regarding providing telehealth services to patients in Iowa. Telehealth visits are permissible via live video or “store and forward” video and the doctor does not need to see the patient in person before seeing them over Skype, Facetime, or some other video conferencing application. Physicians are required to obtain verbal or written consent and document that timely, and have an avenue for patients to access and update their information and lodge complaints. Prescribing is allowed, with restrictions on abortificants, and providers are not allowed to direct patients to websites that advertise or promote goods or products benefiting the provider or websites offering the provider a monetary incentive for sending patients there.

Kansas – Kansas does not currently have any laws regarding telehealth. A law was proposed in 2017, and has not yet made it out of committee. Insurers in Kansas are really fighting against the parity portion of the proposed law. Most other states with telehealth laws require insurances to pay the same for telehealth as they do for in office visits. And, since insurance companies don’t like to pay for anything, they are fighting for the right to pay you less for the same amount of work. Call your representative today. Telehealth does help to lower costs for insurances, though, so many of them will already cover visits done with video conferencing. Check each patients benefits before providing the service. Kansas Medicaid pays for telehealth services for office visits, individual psychotherapy, and pharmacological management services. The consulting expert must bill with the GT modifier and 02 place of service code. Patient must be present at an eligible originating site and written consent is required.

Kentucky – Kentucky gets very specific with the regulations for telehealth. First off, while insurers are required to cover telehealth visits, they are not required to pay the same amount as they would for an in person visit. In most other states, telehealth visits are billed with regular E&M codes. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Only live video is allowed and you need to obtain written consent with very specific statements before the visit. Kentucky Medicaid has very long and detailed guidelines on who can bill for telehealth and how. Please read the article if you are a primary care doctor, mental health provider, dietitian, speech therapist, chiropractor, occupational therapist, physician’s assistant, or optometrist.

Louisiana – The Lousiana Medical Board has been diligent in keeping up with current technology and has issued and revised rules regarding telehealth several times. Currently, providers are not required to do an in person exam prior to the telehealth visit, and the “originating site” for patients can be anywhere the patient chooses. As an added bonus, Louisiana allows providers to use audio only services with online apps or with telephones to provide care to patients. You would need to be careful prescribing controlled substances to patients, but if the patient has had at least one in person visit in the last year, then it is allowed. The patient does need to give specific informed consent and can revoke consent to receive services via telemedicine at any point. Also, psychiatrists cannot prescribe amphetamines for their ADHD patients and telehealth cannot be used for treating obesity.

Maine –  Insurers in Maine are required to cover telemedicine, but there is no parity mandate. For MaineCare patients, telemedicine is allowed more broadly because so much of Maine is rural. Providers can use video conferencing, and “store and forward” video, and, when video conferencing is not available due to the lack of a broadband connection, a telephone visit will be allowed. Here is a list of FAQs for MaineCare telemedicine. Maine requires very specific consent to be documented in the patient’s chart. Please review these rules before engaging in telehealth visits. Maine does not require insurers to pay telehealth visits at the same rate as in person visits. Providers are not required to see a patient in person in order to treat them with telehealth.

Maryland – Maryland has some pending legislation regarding telehealth, so if you are reading this in a few months, the rules may be different. Currently Maryland allows live video only and both the physician and patient need to be in Maryland. The Maryland Board of Physicians have current rules on telehealth that govern physicians responsibilities, and Maryland law requires insurers to cover telehealth, although parity in payment is not required. Providers need to obtain informed consent and can use both live video and “store and forward” video. The new laws will cover prescribing and “practice standards” that the provider will need to meet before each telehealth visit.

Massachusetts – Insurers in Massachusetts are required to cover telemedicine, but there is no mandate for them to pay video visits at the same fee schedule as in person visits. There are two acts currently working their way through the state legislature, but they are both currently in committee. The Massachusetts Medical Society has released several recent opinion pieces and a telemedicine guidelines booklet to aid providers in successfully implementing telemedicine into their practices

Michigan – The telehealth law in Michigan was very recently enacted. SB 0753 took effect on 03/01/17 and does not actually require that insurers pay for telehealth visits and also does not require parity of payment to in person visits. However, insurers WANT their patients to take advantage of telemedicine, especially in states without a parity mandate, because it saves the insurer quite a bit of money. So, check the benefits of the patient’s plan. Because there are no laws, each insurance plan might have strange rules about which kind of conditions can be treated with telemedicine. Before you see the patient, do your due diligence. Michigan requires patients give consent to be treated using this technology, providers can prescribe everything but controlled substances, and telemedicine is defined as two way live video. “Store and forward” video is not payable in Michigan.

Minnesota – Minnesota has very generous telemedicine laws. Insurers are required to pay telemedicine visits at the same rate as they would in person visits and commercial plans are specifically prohibited from charging patients higher copays, coinsurances, and deductibles for these services. Physicians from outside Minnesota can provide telemedicine services to patients in the state by registering with the Minnesota Board of Medical Practice. You would simply need to fill out a one page form and pay a $100 registration fee. You are not required to see a patient in person before treating them via video technology. Patients can use either live two way video, or “store and forward” video. Medicaid limits telemedicine visits to no more than three per week.

Mississippi – Mississippi has joined the side of the provider with laws for telemedicine stating that insurers and Medicaid are required to cover telemedicine, and they must pay the same as they would an in person visit. Only live video and remote monitoring are allowed. Remote monitoring has very specific requirements and if you intend to provide services this way, please review this list. If services are rendered via remote monitoring or “store and forward” video, the modifer GQ is required. I couldn’t find anything regarding requiring specific consent, but it wouldn’t hurt to document in the chart that the patient consents to receive services through telemedicine.

Missouri – There is currently legislation pending in Missouri that would change the landscape of telemedicine in that state, however this post will cover existing laws. An in person visit is required before a patient can receive care via telemedicine, and only health plan approved programs such as LiveHealth online can be utilized. Only live two way video is reimbursable. Providers are allowed to prescribe all medications, even controlled substances. Telephone visits and internet questionnaires are specifically disallowed and providers are not allowed to make any prescription without an in person or video conferencing visit. None of the laws require specific patient consent.

Montana – Insurers in Montana are required to cover telehealth visits at the same rate as in person visits. Both live video and “store and forward” technology can be used for telehealth visits. Providers are not required to obtain specific consent. Montana commercial insurers may have restrictions regarding which platform or software can be used for video conferencing, so check with the patient’s plan before proceeding. In person visits are not required prior to treating a patient via telehealth and you would use the GT modifier.

Nebraska – The Nebraska State Board of Health has a very handy guide to the telehealth statutes in that state. Nebraska providers are required to provide the patient with certain written statements that need to be then signed and a copy needs to be kept in the patient’s chart. The guide I provided above has the requirements clearly laid out. Both live video and “store and forward” video is acceptable for telehealth in Nebraska. Insurers are required to pay the same for telehealth visits as they do for in person visits and telemonitoring is also reimbursable. In order to prescribe, the physician would need an in person visit “to establish care”. There are additional requirements for providing behavioral health services to children and those rules are also in that guide linked above.

Nevada – AB 292 governs telehealth in Nevada. Insurers are required to cover telehealth visits the same as in person visits and providers can use both live two way video and “store and forward” video. Nevada also includes Workers Compensation as covered under the telehealth law with the same requirements as commercial and Medicaid insurers. Use the GT modifier when you bill and prescriptions for telehealth services must follow standard online prescribing rules for the state. Providers must obtain specific written consent. Medicaid requires an in person visit before seeing patients via telehealth, but the state law does not require it for commercial insurers.

New Hampshire – Physicians in New Hampshire can establish a doctor patient relationship via telehealth visits without having an in person visit first, but cannot prescribe any Schedule II -IV drugs. The law specifies that only “real-time two-way communication” (or live video) will qualify. This inclusive guide has billing codes and policies. New Hampshire mostly follows Medicare rules for CMS, without the restrictions on how rural the patient has to be.

New Jersey – New Jersey passed a telehealth law in 2017 and, while insurers are required to cover telehealth visits, they are not required to pay parity. This law is also unique in that it requires live two way video to establish care, but “store and forward” video may be used for subsequent visits if the provider determines that they can provide the same standard of care as they would with in person or live video. Establishing a doctor patient relationship has a specific list of information the provider would need to verify and review. This article at healthcarelawtoday.com breaks down what you need quite clearly. As far as prescribing goes, New Jersey is again unique. Schedule II drugs are not allowed without a prior in person exam, with one exception. A provider may prescribe Schedule II stimulants to minor patients under the age of 18 as long as the visit was with live video and the minor’s parent or guardian has consented to waiving the in-person examination requirement in writing. Patient consent is not specifically required in most cases, but Medicaid does require it for certain specialties.

New Mexico – Commercial insurers in New Mexico are required to pay for telehealth, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. An in person visit is not required to begin treating patients with telehealth and prescribing is allowed under the same regulations that govern online prescribing.

New York – Commercial insurers and Medicaid in New York are required to pay the same for telehealth as they do for in person visits, as long as providers are using live two way video. Insurers MAY pay for “store and forward” video visits, but are not required to. New York also has a special requirement that the camera used in the provider-patient connection be able to tilt and zoom so that the provider can be as observant over video as they would be in person, even for things the patient may not notice or intend to disclose. Written consent is not typically required with the exception of patients receiving mental health services. Bill using the GT modifier. Medicaid does require that the patient be at specific “originating sites”. Here is a list of acceptable originating sites for Medicaid.

North Carolina – Insurers in North Carolina are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. The North Carolina Medical Board has a clear and comprehensive guide on a provider’s responsibilities and options for telehealth. Please note, North Carolina requires staff specifically be trained to use the technology properly.

North Dakota – Insurers in North Dakota are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. The North Dakota Board of Medicine has a short guide on a provider’s responsibilities regarding standard of care and patient consent. An in-person exam is not required to start treating a patient via telehealth and providers can prescribe just as they would in person. The only exception being, providers are not allowed to prescribe opioids at all through telehealth. Two way video and “store and forward” video are both acceptable for telehealth in North Dakota. 

Ohio – Ohio is very concerned about prescribing via telehealth and verifying the identity of the both the patient and the provider. The regulations are quite involved and would take up much more space than I have here. So please go read the informed consent requirements and the prescribing regulations. In Ohio, only Medicaid is required to reimburse providers for telehealth, commercial insurers are not required by law to do so. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill.

Oklahoma – I have to say, I am so impressed with the Oklahoma Medical Board right now. This page is amazingly well organized and informative. The Telemedicine Act (SB726) states that an in person visit is not required to establish care, however, a provider does need to have access to the patient’s medical records prior to the visit. Insurers in Oklahoma are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Providers are not allowed to prescribe either opioids or benzos through telemedicine visits, but other medications can be prescribed as long as the provider is utilizing the same standard of care. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video).

Oregon –  Insurers in Oregon are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Also, some diagnosis may not be covered by telemedicine, or have specific restrictions on under what conditions you can provide telemedicine services. So, please check your patient’s benefits. There are no laws regarding consent or prescribing, but it is always safe to document consent and adhere to the same standard of care for telemedicine as you would for in person visits. 

Pennsylvania – There is currently legislation pending in Pennsylvania. I am writing this in April 2018, so if you are reading it in 2019, please double check the laws in your area. Or email me to update this article. As of the time of this writing, PA does not have any law regarding telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. There are some guidelines that providers wishing to utilize telehealth need to follow. Specific consent must be obtained and documented and two way live video is preferred. 

Rhode Island – Insurers in Rhode Island are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. The law also contains language regarding originating sites that insurances may be able to use to limit a patient’s access to telehealth. Please call to check benefits before you provide telehealth services. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). Patient consent is required and the patient needs to consent to some fairly specific things

South Carolina – As of the time of this writing, SC does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. South Carolina law does state that in order to provide services via telehealth, physicians and staff must be “trained in the use of telemedicine equipment and competent in its operation.” There are no standards to this training or any recommendations on where to be trained. Prescribing is allowed with three exceptions. Providers are not allowed to prescribe any Schedule II or Schedule III drugs, any erectile dysfunction medication, or any abortificants. Medicaid will not compensate providers for “store and forward” telehealth visits. 

South Dakota – As of the time of this writing, SD does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Medicaid will reimburse at parity with in person visits. I have also not been able to find any information about any pending legislation. There are no laws regarding consent or prescribing, but it is always safe to document consent and adhere to the same standard of care for telemedicine as you would for in person visits. 

Tennessee – Insurers in Tennessee are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Consent is required, but may also be “implied consent.” It is probably a good idea to get verbal consent and document that in the chart. Prescribing is allowed to the same standard of care as in person exams. Medicaid will compensate providers for telehealth visits if the patient is in crisis. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). 

Texas – Texas has recently enacted a new law easing the restrictions on providers for telehealth, but the wording of the current law is more vague. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). Consulting doctors need to provide a report to the primary care doctor within 72 business hours. Physicians are not required to see the patient in person to provide services with telehealth. Both two way live video and “store and forward” technology is payable with specific requirements for “store and forward”. The provider needs clinically relevant photographic or video images, including diagnostic images, the patient’s relevant medical records, and a HIPAA conforming technology to comply with the standard of care. The first visit must be with qualified medical staff present at the “originating site” or an in person visit. The Texas Medical Board has a good FAQ on telemedicine

Utah – As of the time of this writing, UT does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Medicaid will pay for telehealth for two way live video only. “Store and forward” video is not reimbursable. Providers can prescribe with telehealth as long as they can obtain and document patient’s relevant clinical history and current symptoms, be available for subsequent care related to the initial telemedicine services, be familiar with available medical resources, including emergency resources near the originating site, in order to make appropriate patient referrals when medically indicated, and make the patient’s medical records available to them. 

Vermont – Insurers in Vermont are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Providers need to obtain the patient’s verbal or written consent and document that in the chart. Providers may prescribe via telehealth as long as they keep to the same standard of care as in person visits. Patients are not required any longer to be in a healthcare facility as the originating site. Vermont has specific wording in their new law stating the telehealth consultations cannot be recorded and only live two way video is allowed. 

Virginia – The Virginia Department of Health Professions has issued Guidance document: 85-12 in regards to a physician’s responsibilities regarding treating patients via telehealth. It is a five page document and contains the information regarding consent (needed, specific), privacy (practice needs written policy), and prescribing. Insurers in Virginia are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. 

Washington – Insurers in Washington are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. There is no specific requirement for consent and prescribing is held to “the same standard of care” as in person exams. An in person exam is not required in order to treat a patient via telehealth. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). 

West Virginia – As of the time of this writing, WV does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Medicaid currently only covers live video and not “store and forward” technology. Patient consent is required to be obtained and documented, and prescribing is allowed, but any scheduled pain relieving drugs are not permitted to be prescribed via a telehealth visit. In person visits only. While an in person visit is not required, the provider has a very specific list of things to do to “establish care” with a telehealth visit. Please see this article for the complete list. 

Wisconsin – As of the time of this writing, WI does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. The medical board has issued brief guidelines for providers utilizing telehealth. Patient consent is required to be obtained and documented, prescribing is allowed, and you do not need an in person visit first in order to establish care. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). 

Wyoming – As of the time of this writing, WY does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. There is no specific requirement for consent and prescribing is held to “the same standard of care” as in person exams. An in person exam is not required in order to treat a patient via telehealth. The Northwest Regional Telehealth Center has a page on telehealth in Wyoming and they also have an easy way for you to ask more questions if you have them. 

Two quick things. “Originating site” is wherever the patient is. Previous incarnations of many state laws required patients to be in a healthcare facility to receive telehealth services. Those requirements are basically a thing of the past. Also, many states are concerned about patient consent, because of the slight risk to patient privacy during telehealth visits. In your office, you can room a patient and close the door, giving the patient a reasonable expectation of privacy. When they are at home, or in their office, or walking around the grocery store, you can’t control the privacy of the information on their end. So, they need to consent to be responsible for their own privacy since you are not there to ensure it. 

As always, contact me if you need any help or have any questions. We will be adding a telehealth topic into the roster of our available online webinars, so email me at newgenerationbilling@gmail.com if you would like to sign up. The landscape of medicine is changing very quickly, and the more information you have, the better you can decide what is right for your practice. 

 

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Filed under Billing, Health Care, Medical Billing, Medicare, Office policy, Telehealth

Prospect is not sending EOBs anymore as of 09/01/17

Hello everyone! Just a quick public service announcement. 

Prospect, and all of the IPAs that it administers, will not be sending paper EOBs anymore. The claims and authorizations website doesn’t have them in a way that is easy to get by date, so you need to sign up with your clearinghouse to receive the 835 ERA files. 

Those IPAs include: 

Prospect

Nuestra Familia

Genesis

Gateway

Pomona Valley Medical Group aka PVMG aka ProMed

Upland Medical Group

This DOES NOT include Prospect LA Care because that is administered by MedPoint Management. Because why not. 

I use Office Ally, so, that is the only one I will really be able to help you get enrolled with. Here is the 835 ERA form  that you would need to fax in to get your EOBs electronically. 

If you use a different clearinghouse, call them to get the proper forms. Some of you may have billing systems that handle your claim, eligibility, and ERA set up on your behalf with the clearinghouse. Not a comprehensive list by any means, but if you use Advanced MD, WebEDoctor, or Athena, you need to call your software support people directly, and the sooner the better. 

This is really for my Southern California providers and billing services. Heads up guys. 

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Filed under HMO, Medical Billing, public service announcement

Any anesthesiologists in the house? And by “the house” I mean California.

I don’t know how many of my California anesthesiologist readers are contracted with Medi-Cal, but I am sure there are a few of you. 

I am also sure that you know how little they pay you. But, I have recently figured out a way to get them to pay you a small amount more. 

Usually, Medi-Cal will only pay for anesthesia for one service per day. It had never mattered that the anesthesia was for a different surgery at a different time on a different body part. 

But in 2015 CMS started using the X (EPSU) modifiers. Applying them to the appropriate line item has allowed me to increase my provider’s reimbursement from Medi-Cal to all line items submitted on the claim. The modifiers are as follows: 

  • XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
  • XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”
  • XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”
  • XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”

Use the modifier on the line that pays less, just in case the automatic processing system decides it hates your particular claim. Also, since Medi-Cal does not accept more than one modifier per line, remember to use your 99 and indicate the modifiers in box 19. 

Call or email with any questions. 

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Filed under Anesthesia, Medi-Cal, Medical Billing, Modifiers

When Medicare says 365 days, they mean 365 days.

Gentle readers,

It is flu shot season. And do-the-physicals-on-your-Medicare patients-before-they-go-somewhere-else-and-another-office-bills-the-physical season. And I am seeing a lot of the same question from both my billing service providers, and from you, my gentle readers.

Specifically, you billed/coded the flu shots and physicals the way I taught you and they are still getting denied! What gives?

And here is your unfortunate answer.

Medicare will pay a flu shot once every 365 days. They will pay a physical once every 365 days. They will pay a pap once every 730 days for a woman at normal risk and once every 365 days for a woman at high risk. They will pay the pneumo vaccine once every 365 days.

That means that if a patient came in on Feb 17th 2016 to get their flu shot last year and then came in this year on Jan 25th and got another flu shot, you will not get paid. Even if you bill with ICD10 Z23. Even if you bill with the Q-code for the vaccine. Medicare does not care that it is a different flu season. They do not care that your patient will be visiting their newborn grandson in a couple weeks and they need to be up to date on their immunizations. They do not care that your patient is going for a month long cruise in the caribbean and this is the last date they have available until they get back and they would prefer to get it done before they are rubbing elbows with a bunch of strangers who may have the flu.

Medicare does not care.

And they really mean 365 days. Not 364. So, when a patient needs a preventive service, please try and train your doctors and your office staff to check the date the patient received their last preventive service. The Medicare site also has a tab under the eligibility lookup section to check and see when the patient is next eligible for a preventive service. Here is a screenshot of the page and what it looks like:

medicare-prev-screen-shot-1

As you can see, the date the patient is going to be eligible for any specific service is indicated on the right. Flu and Prevnar are not included in this list, so you will need to rely on your records to track those. 

Below is the link to a good website for more information on the Medicare policies for preventive services. 

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Keep emailing your questions and I’ll keep giving you answers. 

 

 

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Filed under Flu Shot, Immunizations, Medical Billing, Medicare, Preventative services, Vaccinations

Heads up for my ophthalmologist friends

Hello my ophthalmologist friends!

Medicare is changing the rules for the 92235 and the 92240. Up until 2017 we would bill two line items of those codes with RT/LT modifiers. According to the new edits, as of 2017 those codes are bilateral. If you separate them and use the RT/LT modifiers your claim will be denied. 

If you already sent them that way, you can use your local Medicare site to do a simple claim correction and get that updated. 

For the FA and the ICG this year, you bill just one line item with no modifiers. And, yes, we will get paid less. 

Sorry. 

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Filed under CMS, Medical Billing, Medicare, Modifiers, ophthalmology