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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