October 9, 2020 | Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content, innoviHealth
If you are an active coder or auditor, you are likely keenly aware of the abundant changes to healthcare laws, regulations, policies, and guidelines surrounding HIPAA, coding, reimbursement, and especially to the integration and rapid expansion of telemedicine services. Since the beginning of the COVID-19 public health emergency (PHE), this vast array of changes left us in a quandary as to whether we have the most current information or have possibly missed something. Generally, during an economic downturn, the healthcare industry continues to do business as usual. But during this PHE, it has suffered for many reasons, such as risk of spreading COVID-19 to patients and staff, lack of sufficient protective gear, essential and nonessential services being identified and governed differently from state to state, and many practices stumbling to establish telemedicine services as an option for their patients.
Now, more than ever, it is vital that we carefully monitor documentation, services, and claims submissions to ensure accuracy and avoid potential revenue loss. This is done by creating a compliance plan and addressing the specific needs of your organization. To get started, begin identifying the specific needs of your organization following the steps shown here:
- Identify the provider contracts for your organization.
- Run a report that identifies the payers with the most beneficiaries seen in your organization. Identify, for example, what percentage of Medicare and Medicare Advantage beneficiaries your organization sees annually.
- Create and maintain a file on each payer contract.
- Access the payer’s website to identify:
- Outside of the PHE, which coding guidelines they say they follow (e.g., CPT/HCPCS, Medicare, or their own).
- During the PHE, what policy changes they have made, especially regarding telemedicine services, coinsurance and copayment waivers, and any published date ranges during which these changes will be considered valid.
- Verify the licensing and scope of practice for each provider in your organization is up to date and that exclusion screening has been done.
- Audit up to 5-10 claims per provider for each payer to determine accuracy. Specifically, audit services rendered during the PHE and target specific claims (e.g., telemedicine E/M services, COVID-19 diagnostic testing) to ensure accuracy.
- Maintain a spreadsheet for each claim by payer and provider to easily identify issues.
- Communicate with the attorney as needed to properly handle any negative findings that may have caused overpayments to determine proper handling.
- Educate providers and coding staff in areas where improvement is required.
- Update the compliance plan to specify which things were done and when.
- Review each payer’s website for alerts and policy changes moving forward until the PHE has subsided.
- Re-audit, as needed, to maintain the highest reporting accuracy.
By staying on top of the information being published by the payers you do the most business with, you will begin to feel like you have some control over how your organization is dealing with the PHE. To show how easy it is to miss vital information that can make all the difference when it comes to provider documentation, review the following excerpt that was published in a 125-page document in the Federal Register on April 6, 2020 (CMS-1744-IFC) :
“On an interim basis, we are revising our policy to specify that the office/outpatient E/M level selection for these services when furnished via telehealth can be based on MDM or time, with time defined as all of the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and/or physical exam in the medical record.”
This paragraph was located in the section titled, “W. Level Selection for Office/Outpatient E/M Visits When Furnished Via Medicare Telehealth” of the CY 2020 PFS final rule (84 FR 62847 and 62848). This section explains that the changes to Office/Other Outpatient E/M Services (99201-99215), which have been scheduled for implementation on January 1, 2021, could immediately be implemented (retroactive to March 31, 2020) for telehealth E/M services provided to Medicare beneficiaries. As you are probably aware by now, as of January 1, 2021, E/M services for this category of codes (99201-99215) will be revised to include the following changes:
- Deleted new patient code 99201
- Established patient code 99211 specific to clinical staff services supervised by a physician/NPP/QHP
- History and examination no longer part of the scoring process to determine the E/M level
- Documentation of a clinically appropriate history and examination, is left to the discretion of the physician/NPP/QHP
- The level of E/M service reported may be determined by time or MDM:
- Time: Total time may be used to determine the level of E/M service reported. This includes both face-to-face and certain qualifying activities for non-face-to-face time spent by the physician/NPP/QHP.
- Medical Decision Making (MDM): Identifying the number and complexity of problems addressed, amount and/or complexity of data reviewed and analyzed, and the risk of patient management may be scored to determine the level of service.
- Prolonged Services codes, descriptions, and guidelines have been revised
- A new Prolonged Services code (99XXX recently revealed by the AMA as 99417) has been added and is only reportable with codes 99205 or 99215.
Amid the massive influx of information and policy changes published during the PHE, this CMS policy revision allows providers to begin using the 2021 E/M guidelines for office/other outpatient services (99201-99215) beginning March 31, 2020 through the end of the PHE. We’ve all heard those rumors that “they aren’t going to audit provider services during the PHE,” but as any good auditor well knows, when policy changes are made and there is an increase in utilization of any particular service type (e.g., E/M telemedicine), payer audits targeting that service type will be sure to follow. We need to know the specific payer guidelines and ensure our organizations are compliant so when the audit comes, we are ready.
Here are a few questions to consider in response to this Medicare announcement back in April:
- Do you know if any of your commercial payer contracts have adopted this guideline change from Medicare?
- Are the physicians and other qualified healthcare professionals (QHPs) such as non-physician practitioners (NPPs) in your organization educated and trained on the documentation requirements specific to these new E/M guideline changes and scoring processes?
- Do your audit tools allow you to review a telemedicine E/M service using the CPT guidelines, Medicare 1995 and 1997 guidelines, and the CPT 2021 guidelines?
- Does your compliance plan have a section specific to how policy changes, coinsurance and copay waivers will be managed during the PHE?
- Are you keeping a copy of the policy changes that have been published for easy reference?
By planning, organizing resources, educating staff, and auditing for compliance, you will be better prepared to face an audit when it occurs.