Claim Denial Telehealth: Check 2 Items Before Refiling

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Claim Denial Telehealth: Check 2 Items Before Refiling

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Telehealth Claim Denial

QUESTION: We just received our first denial for a telehealth service using audio-visual. The claim was filed with office visit code 99212, place of service 02 for telehealth and modifier 95. Can you tell us what we did wrong so that we can get paid for these visits?

Question from Palatine, Illinois Subscriber

ANSWER: Based on the information you provided, there are two areas that could have triggered the denial of your telehealth claims:

1. Modifier Error:

Insurers have various rules for modifiers. Accordingly, the payer that denied your claims could require a different modifier. To decide if changing the modifier on your claim can fix the problem and get it paid, check the insurer-specific guidelines. Here are several insurer guidelines related to telehealth:

    • Medicare and Medicaid: Requires modifier 95 as of claims with dates of service March 1, 2020. This is per the March 30th, 2020, CMS Interim Final Rule.
    • Blue Cross Blue Shield (BCBS): Requirements vary by state and plan. For instance, BCBS of Illinois requires modifier 95 for telehealth services, but other state plans may not.
    • CIGNA: Requires modifier 95 or GT (Interactive audio and video telecommunication system).
    • United Health Care: Modifier GQ (Asynchronous telecommunications system) or GT is required.

Tip: In the absence of guidance, stick with modifier 95 (Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System). This is a CPT modifier introduced in 2017 that you can append to the codes listed in CPT Appendix P.

2. Place of Service (POS) Edit Processing Delay:

You may have submitted your claim correctly, and still received a denial. Again, insurers’ policies vary. In addition, Medicare and Medcaid recently changed their POS guidance.

    • CMS: Requires usual POS code. According to the March 30th, 2020, CMS Interim Final Rule, you should now use the POS that represents the location where the service usually would have taken place outside of the Public Health Emergency (PHE) guidelines. For example, for an office visit via telehealth, you should use a POS of 11 (Office visit). using a POS of 02 reduces the payment by 15%, so for full reimbursement, follow the new policy.
    • Private payers: A POS of telehealth (02) is still required by most third-party insurers.

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Meet Your Writer

Jen Godreau CPC, CPMA, CPEDC, COPC Content Director

Jennifer Godreau, CPC, CPMA, CPEDC, COPC, has almost 20 years of experience in billing, coding, compliance, and practice management. She develops the content and programs for Healthcare Training Leader, a practice-specific online training company offering step-by-step advice on increasing reimbursement and avoiding compliance violations. Prior to joining Healthcare Training Leader, Jennifer supervised the program delivery for EMRs, practice management systems and compliance and revenue cycle services for more than 6,000 providers. Thousands of software products - encoders, claims management, auditing, and HIPAA compliance, have been created with her teams and helped thousands of practices more easily reduce revenue losses and comply with complex regulations. Her passion for breaking down healthcare rules and requirements in simple steps has provided practical advice, education, and risk reduction strategies to numerous associations, payers and medical specialties especially in primary care, otolaryngology, eye care, and pediatrics. Jennifer’s advocacy resulted in supervision rule revisions, new CPT codes, and CMS compliance contracts. She oversaw the provider auditing and education for one of the major corporate integrity health system settlements. Jennifer has authored and presented on numerous healthcare compliance and payment challenges. Her education guides include the Certified Otolaryngology Coder (CENTC) exam study guide and the AAPC Professional Medical Coding Curriculum. Jennifer has a Bachelor of Arts from Wittenberg University in Springfield, Ohio. She holds certificates in coding, auditing, pediatric coding, and ophthalmology billing and coding, and is AAPC Vice President of the Naples, FL chapter. Please reach out to Jennifer for step-by-step guidance at editorial@hctrainingleader.com