ED Coding and Reimbursement Alert

Wondering about the new telehealth modifier? We’ve got answers.

From reporting split/shared services to moving forward with another year of telehealth, there may be some coding and billing updates for 2022 that you’ve missed. To rectify that and ensure you’re up to speed with all of Medicare’s requirements, we’re sharing a few tips that can help you stay on the right side of the rules.

Check out these updates, shared by CGS Medicare reps Towanna Tripp, CPC, and Vanessa Williams during the Part B MAC’s February 16 webinar, “Part B Customer Service FAQs.”

Update Your Code Books and Check Them Regularly

Make sure you have the most current CPT^®, HCPCS, and ICD-10-CM code books at the beginning of every year, Tripp advised. “Please, please know that this is part of your job and that your office should be paying for that — it’s material that you have to use for coding.” If you aren’t yet in possession of the 2022 code manuals, it’s time to buy them, whether that means you get a digital copy or a paper copy of the books.

She also stressed the importance of reviewing claims before you submit rather than just assuming the right codes are listed in the record. “Before submitting a claim, the coder should ensure that the correct procedure and diagnosis codes are used,” Tripp said. “Check the documentation and other information if necessary.”

MAC Customer Service Reps Can’t Choose Your Codes

If you get stuck about which code to report and you plan to call your Part B MAC rep for coding advice, think again. “Always remember that customer service representatives cannot code,” Tripp said. “They’re not coders, nor are they clinicians, and they cannot code for you.”

For that reason, providers should always review patients’ medical records and documentation, along with all appropriate resources, to ensure that the practice is submitting services correctly, she advised. If the providers’ records are thorough, the coder shouldn’t have trouble selecting the right codes for the service.

Mind Your Modifiers

It’s important to know the ins and outs of all the modifiers and understand how to use them. “If you don’t know what modifier to use, check with your team,” said Tripp.

For example, she said, a provider performed joint injections (20610, Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) on both of a patient’s shoulders, as well as one in the patient’s left hip. The practice reported the services as follows:

• 20610-RT (Right side) for the right shoulder
• 20610-LT (Left side) for the left shoulder
• 20610-LT (Left side) for the left hip

“So in this example, multiple units were billed on the same date using left side and right side modifiers,” Tripp said. “The system has no way of knowing where the injections were given, so the practice would get a denial for exceeding the frequency of services.” The reason for denial, she said, is that the anatomical modifiers don’t tell the payer why multiple injections were performed.

“Therefore, the claim is hitting the medically unlikely edits (MUEs),” Tripp said. “The medically unlikely edits are used by the Medicare contractors to reduce the improper payment rate for Part B claims. You can identify the intentional repeat use of 20610-LT by appending modifier 59 (Distinct procedural service) to indicate the left hip injection was performed during the same session or encounter as the left shoulder injection.

Appeal in a Timely Manner

If you do face a denial due to the MUEs, “More than likely you’re going to have to appeal it with documentation,” Tripp said. “So now you’re on time crunch. If you get this type of denial, resolve it right away, because with an appeal, you only have 120 days to appeal. Don’t wait until almost a year after the denial and then try to figure out how to resolve it.”

Contrary to what some practices believe, payers aren’t opposed to appeals if you are trying to make something right. “We want you to ask for your money,” Tripp said. “But as always, things have to have to be done in the correct order.”

The process for appealing will be clearly listed on each MAC’s website, she noted. You should check there before calling customer service so you can save time and see the process in writing. That way, you can swiftly follow it and file your appeal.

Identify Drugs You Inject/Infuse

If you inject or infuse a drug, don’t forget to bill for the medication using the appropriate HCPCS code for your facility claims, Tripp said. “Please remember if you are going to send us in a charge for the administration of a drug, you’ve got to tell us what the drug is. We don’t know and we can’t automatically pay it.”

Of course, there’s no guarantee your claim will be paid if you report the drug code, but you know for sure that the claim is unlikely to be processed correctly without it, she added.

Know the Telehealth Device Rules

One of the most frequently asked questions that MAC claims reps get is whether any specialized equipment is needed to furnish Medicare telehealth services, Williams said. “And the answer is that currently, CMS requires most telehealth services to be furnished using telecommunications technology that has audio and video capabilities that are used for two-way, real-time interactive communication between the patient and the distant site physician or practitioner.”

During the public health emergency (PHE), Medicare will also pay you for codes 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment…).

These codes describe audio-only phone visits for practitioners who can independently bill for E/M services, Williams said. “As for all Medicare telehealth services furnished during the PHE, please report the place of service code that would have applied if the service had occurred in person for these telephone-only telehealth service codes along with the 95 modifier (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system).”

Understand Split/Shared E/Ms

Remember that the rules for reporting split/shared visits changed this year. When the physician and a nonphysician provider (NPP) from the same ED group share an E/M visit, “the visit is billed by the physician or practitioner who provides the substantive portion of the visit,” Williams said.

“For 2022, the substantive portion can be the history, physical exam, medical decision making, or more than half of the total time (except for critical care, which can only be more than half of the total time),” she noted.

You should append modifier FS (Split (or shared) evaluation and management visit) to the appropriate E/M visit code (99281-99285), Williams added. This allows the MAC to see that the physician and the NPP shared the visit.