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Telemedicine & Telehealth Billing: A Practical Guide & Reasons to Outsource

| April 17, 2020

Telemedicine & Telehealth Billing: A Practical Guide & Reasons to Outsource

Once an emerging form of medical care, telemedicine and telehealth services have grown into a viable option for many healthcare providers. In fact, the Centers for Medicare and Medicaid Services (CMS) under the current administration have touted telemedicine and telehealth as a critical part of the current healthcare system in the United States, with over 76% of hospitals in the country engaging in telehealth consultations. Recently, the AMA reported that telehealth is growing faster than any other type of medical care, experiencing a 53% growth in a 2019 study.

These changes were triggered by a number of external factors. First, the increasing consolidation and the related centralization of healthcare services has made the task of finding an in-network provider much more difficult for some Americans. It also promoted the diversification of many health organization’s offerings. Now more than ever, individuals with limited access to regular medical care due to geographic, transportation, or physical constraints can receive care through telemedicine.

In addition, the 2020 COVID-19 pandemic necessitated a rapid shift in priorities for a number of organizations, including Medicare and Medicaid, which now allow a massively extended number of telehealth services. Telehealth allows providers to screen patients first before providing virus-related or emergent care on an in-person basis. For others who need regularly-scheduled medical care, telemedicine services allow patients to receive a wide range of services from home without exposure to other individuals and environments that may harbor the virus.

A Guide to Telehealth and Telemedicine Billing

First and foremost, while telehealth and telemedicine are often used interchangeably – even by physicians – there are some important historical differences between the two according to the AAFP. Telemedicine was traditionally used to describe any use of technology in a medical setting, whereas telehealth referred to the use of technology to provide patient treatment. Currently, both are used to describe remote interaction with and treatment of patients using technology.

Another key set of terms involves the provider’s and the patient’s locations during the telehealth visit as well as the type of practice providing the service are:

  • Originating site
    Primarily used in conjunction with Medicare, this term refers to the patient’s location during treatment. This must be an approved address for the patient to receive health services and for Medicare purposes must be located in a health professional shortage area.
  • Distant site
    This term is used to refer to the provider’s location during a telehealth visit. It is also used to specify which types of providers can provide insurance-covered telehealth visits, including physicians, PAs, NPs, Certified Nurse Midwives, clinical psychologists and social workers, registered dieticians, and clinical nurse specialists.
  • Place of service
    This portion of a medical code for billing purposes informs the payer of the location of both the originating site and the distant site. Since payer rates often depend on the physician’s location during the service, the place of service is a crucial factor to consider when billing for telemedicine.
  • Practice type
    This kind of medical billing code informs the payer what type of practice provided the service. Depending on whether the service originates from a private practice, hospital-based clinic, rural clinic or other, payers may extend coverage or choose to deny claims based on the patient’s policy.

To begin the billing cycle, providers must first clear the use of telehealth with the patient’s insurance company or other payer. In most cases, this involves a phone call to the payer to verify coverage, as well as the specific listing of a code used to identify the place of service as well as the particular telehealth service to be provided. As mentioned, different payers, as well as different legal entities, hold different requirements to determine eligibility; depending on the coded procedure, you may need to meet specific distance, provider-patient relationship, patient consent, and other qualifications for the payer to cover the telehealth visit.

Common Telehealth Billing Codes

Medical practices in the United States use one primary set of telehealth billing codes designed to assist payers, providers, patients, and patients alike to determine coverage as well as the medical necessity of the procedure. This list, known as the Current Procedural Terminology, is a code set developed by the American Medical Association’s CPT Editorial Panel.
These CPT codes, in conjunction with the International Classification of Diseases, or ICD, codes, set up an index of possible services rendered by the practitioner in accordance with the corresponding diagnoses listed by the ICD. Once each telehealth interaction or procedure receives a code, the billing department can bill the payer via a clearinghouse or directly. In most cases, this involves electronically submitting an ANSI 837 file on the Electronic Data Interchange (EDI).

Common CPT Codes

While an ever-increasing number of telehealth services are becoming available, there are several common telemedicine CPT codes used by providers. Frequently used telehealth CPT codes include:

  • 99201-99215: either new or previously established telehealth office visits for outpatients
  • G0406-G0408: follow ups to inpatient telehealth consultations
  • G0425-G0427: telehealth consultations as a follow up to inpatient or emergency treatment
  • G2012, G2010: brief 10-15 minute check-in for an established patient to determine if an office visit is necessary or to analyze video or photos provided by the patient
  • 99431, 99422, 99423, G2061, G2062, G2063: communication between an established patient and a provider through the provider’s online portal, otherwise known as E-visits
  • 90832-90828: individual psychotherapy service
  • G0108-G0109: group or individual diabetes self-management training
  • 90963-90969: end-stage renal disease treatment with home dialysis
  • G0396, G0397: alcohol and substance abuse structured intervention and treatment
  • G0270, 97802-97804: group and individual medical nutrition therapy
  • G0438: annual wellness visit

Additional CPT codes as well as CMS approved CPT codes due to COVID-19 can be found in the CMS guidance. In addition, providers should pay particular attention to code modifiers like G0, GQ, GT and GY to add further specificity to a code and increase its potential for payment.

Completing the Telehealth Billing Process

Once the payer receives the billed claims, a medical claims adjuster will determine approval, denial, or a failed claim based on the necessity of the service as well as the eligibility of the patient’s coverage. If a claim is approved, the insurance company provides reimbursement based on a pre-approved rate.

Failed and denied claims are sent back to the provider with an explanation of benefits (EOB) who must then make the necessary corrections and resubmit the claim. Sometimes, this process happens repeatedly until the payer agrees to pay the requested reimbursement or the provider accepts a partial payment. Most often, denied telehealth claims stem from improper attention to the originating site, distant site, and codes accepted by payers like Medicare and Medicaid, both of whom assign strict provisions to the reasons behind telehealth procedures. Unfortunately, these denials cost an average of 3.3% of your total revenue each year.

Consider Outsourcing Your Telehealth and Telemedicine Billing

As mentioned above, ensuring you receive reimbursement for your telehealth procedures can be a tricky process involving CPT code modifiers. To streamline workflow, many practitioners are turning to an electronic management service to provide an electronic health record, or EHR, for each patient. Through the use of EHR software, you can gather a substantial amount of the data necessary to perform analysis on your telehealth billed services.

However, simply instituting a software program does not provide you with the in-depth analysis you’ll need to continue to grow your practice. As you know, busy physicians and other practitioners are often hard-pressed to take on administrative duties in addition to other patient-centered responsibilities. As a result, outsourcing telehealth billing to a third-party vendor is a common solution.

You’ll glean multiple benefits from outsourcing your telehealth billing to a medical billing firm, including:

  • Specialized Teams
    Telehealth billing firms employ experienced medical coding and billing experts with a focus on telehealth requirements for Medicare, Medicaid, and major insurance providers. A knowledgeable team with sophisticated software can help prevent the $118 spend per claim denial appeal by improving claim accuracy from the outset.
  • Medical coding and billing
    Particularly in the telehealth arena after COVID-19 – is a rapidly changing discipline. A third-party firm is able to focus on ongoing training and certifications in order to keep its team up-to-date and proficient.
  • Cost decreases
    As opposed to staffing your own billing department, outsourcing your telehealth billing allows you to pay less for expertise. Better yet, you won’t take on the additional overhead costs associated with adding an additional workforce to your practice, further increasing your opportunity for revenue.
  • Reduced Errors
    According to legal firm Husch Blackwell, “by far, the most common errors in claims submitted for telehealth services were related to the location of the originating site.” Reducing these errors can help you ensure you receive reimbursement for your services.
  • Quicker, more efficient returns
    With an expert workforce at your fingertips, claims can be submitted in a matter of hours instead of a matter of days. Better yet, through the use of automated EHR software, you could be looking at verification costs under 50 cents instead of the $8 required by the manual billing process.
  • More time for patient care
    Reduced attention to administrative details allows you to place your focus where it needs to be – on your patients. Patient engagement and minimal after-office-hours results in a better standard of care as well as a better reputation.
  • Increased revenue potential
    While each of the above reasons contributes to the increased potential for revenue the majority of physicians see as a result of outsourcing telehealth billing, the true potential lies in the work a telehealth billing firm will put in. A good billing firm will perform a fee schedule analysis and work towards improving your collection rate to make sure you receive your reimbursements.

How to Choose an Experienced Telehealth and Telemedicine Billing Company

If you’re like the countless physicians who have added telehealth to their services list, you may now be experiencing more medical billing uncertainty than ever. Instead of taking on the task of providing training, adjusting to frequent payer regulation changes, and paying your own coding and billing staff, consider hiring an experienced medical billing company. A third-party team can focus on the nuances of your telehealth billing while you continue to focus on your patients.

However, it’s important to find the right team to tackle this crucial aspect of your practice. You’ll need a medical billing company with a top of the line EHR software, continuous training and resources, transparency in its collection and claims techniques, and a deep knowledge of the changing industry. Perhaps even more importantly, you’ll need a medical billing company just as dedicated to boosting your revenue as you are.

Embrace Telehealth and Telemedicine By Outsourcing Your Medical Billing Needs

No matter the size of your practice, outsourcing your telehealth and other medical billing needs reduces your overhead and allows you to focus on the everyday concerns of running your practice. Meanwhile, increased accuracy and transparency of data enables you to optimize collections and view KPI for future growth. Best of all, as the field of telemedicine continues to change, you can rest assured your medical billing team will adapt, enabling you to reach more patients than ever before.

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