Tag: Billing Guidance

Telehealth Landscape Overview 50 States + DC

No two states are alike in how telehealth is defined and regulated. While there are some similarities in language, perhaps indicating states may have utilized existing verbiage from other states, noticeable differences exist. These differences are to be expected, given that each state defines its Medicaid policy parameters, but it also creates a confusing environment for telehealth participants to navigate, particularly when a health system or practitioner provides health care services in multiple states. In most cases, states have moved away from duplicating Medicare’s restrictive telehealth policy, with some reimbursing a wide range of practitioners and services, with little to no restrictions.

One of the most common trends with live video reimbursement was the addition of eligible services to the list of telehealth eligible services, with applied behavioral analysis being the most common service addition mentioned in Medicaid manuals.

Additionally, in the wake of the COVID-19 pandemic, some states do seem to be adopting the Center for Medicare and Medicaid Services (CMS) communication technology-based services (CTBS) codes, including the virtual check-in and remote evaluation of prerecorded information, audio-only service codes and remote physiologic monitoring. All fifty states and the District of Columbia have a definition in law, regulation, or their Medicaid program for telehealth, telemedicine, or both.

Additionally, because of the allowance in most states to utilize telephone as a form of telehealth during COVID-19, some states are taking steps to broaden its permanent definitions of telehealth or telemedicine by removing the explicit exclusion of telephone or including audio-only services within the definition itself. One of the states with the most significant changes to their telehealth policy was Massachusetts which passed a comprehensive telehealth law to require reimbursement for both Medicaid and private payers if the services are covered in-person and it is appropriately delivered through telehealth. The law contained some unique elements including specifying that the rate of payment for telehealth services provided via interactive audio-video technology and audio-only telephone may be greater than the rate of payment for the same services delivered by other telehealth modalities. It also provided payment parity for in-network providers of behavioral health services delivered via interactive audio-video technology or audio-only telephone only.

Additional findings include:

  • 50 states and Washington DC provide reimbursement for some form of live video in Medicaid fee-for-service.
  • 22 state Medicaid programs reimburse for store-and-forward. However, three states (NC, OH, VT) solely reimburse store-and-forward asa part of CTBS, which is limited to specific codes and reimbursement amounts. Additionally, three  jurisdictions (MS, NH, and NJ) have laws requiring Medicaid reimburse for store-and-forward but as of this time, have yet to have anyofficial Medicaid policy indicating this is occurring. 
  • 26 state Medicaid programs provide reimbursement for RPM. As is the case for store and-forward, two Medicaid programs (HI and NJ) have laws requiring Medicaid reimburse for RPM but at the time this response was written, did not have any official Medicaid policy. Additionally, one state (Ohio) only reimburses the remote physiologic monitoring codes CMS does.
  • 14 state Medicaid programs (Alaska, Arizona, Colorado, Maryland, Maine, Minnesota, Missouri, North Carolina, New York, Ohio, Oregon,Texas, Vermont and Virginia) reimburse for all three, although certain limitations apply.
  • 43 states and the District of Columbia have laws that govern private payer reimbursement of telehealth. Some laws require reimbursement be equal to in-person coverage, however most only require parity in covered services, not reimbursement amount. Not all laws mandate reimbursement coverage parity, and very few have explicit payment parity

Cognitive Assessment & Care Plan Services

If your patient shows signs of cognitive impairment during a routine visit, Medicare covers a separate visit to more thoroughly assess your patient’s cognitive function and develop a care plan – use CPT code 99483 to bill for this service. 

Effective January 1, 2021, Medicare increased payment for these services to $282 (may be geographically adjusted) when provided in an office setting, added these services to the definition of primary care services in the Medicare Shared Savings Program, and permanently covered these services via telehealth. Use CPT code 99483 to bill for both in-person and telehealth services.

How Do I Get Started?

Detecting cognitive impairment is a required element of Medicare’s Annual Wellness Visit (AWV). You can also detect cognitive impairment as part of a routine visit through direct observation or by considering information from the patient, family, friends, caregivers, and others. You may also use a brief cognitive test and evaluate health disparities, chronic conditions, and other factors that contribute to increased risk of cognitive impairment.

If you detect cognitive impairment at an AWV or other routine visit, you may perform a more detailed cognitive assessment and develop a care plan during a separate visit. This additional evaluation may be helpful to diagnose a person with dementia, such as Alzheimer’s disease, and to identify treatable causes or co-occurring conditions such as depression or anxiety. 

Who Can Offer a Cognitive Assessment?  

Any clinician eligible to report evaluation and management (E/M) services can offer this service. Eligible providers include: 

  • Physicians (MD and DO)
  • Nurse practitioners
  • Clinical nurse specialists
  • Physician assistants

Where Can I Perform the Cognitive Assessment?   

You can perform the assessment at any of these locations:

  • Office or outpatient setting
  • Private residence
  • Care facility
  • Rest home
  • Via telehealth

What’s Included in a Cognitive Assessment? 

The cognitive assessment includes a detailed history and patient exam. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483. An independent historian can be a parent, spouse, guardian, or another individual who provides patient history when a patient isn’t able to provide complete or reliable medical history. 

Typically, you would spend 50 minutes face-to-face with the patient and independent historian to perform the following elements during the cognitive assessment: 

  • Examine the patient with a focus on observing cognition 
  • Record and review the patient’s history, reports, and records 
  • Conduct a functional assessment of Basic and Instrumental Activities of Daily Living, including decision-making capacity
  • Use standardized instruments for staging of dementia like the Functional Assessment Staging Test (FAST) and Clinical Dementia Rating (CDR)
  • Reconcile and review for high-risk medications, if applicable 
  • Use standardized screening instruments to evaluate for neuropsychiatric and behavioral symptoms, including depression and anxiety
  • Conduct a safety evaluation for home and motor vehicle operation 
  • Identify social supports including how much caregivers know and are willing to provide care
  • Address Advance Care Planning and any palliative care needs 

NOTES

Notes

Data reflect NCQA’s 2019 ratings of Medicaid managed care plans. The plans included in the NCQA data do not always match the MCOs in other tables in the Medicaid Managed Care Market Tracker, or they may appear under different names. Discrepancies may be due to differences across reports and sources, timeframes, and other factors. MCOs not accredited or rated by NCQA may be accredited or rated by other organizations.

The NCQA plan overall rating scale is 0-5 (0 is lower performance, 5 is higher performance). NCQA accreditation is as of June 30, 2018. For more information about how NCQA rates plans, please see NCQA’s methodology.

Sources

NCQA Health Insurance Plan Ratings 2018-2019 – Summary Report (Medicaid). Special Data Request, October 2019.

Definitions

Partial Data Reported: Plans with partial data do not receive a rating, but NCQA lists them in the ratings and shows their scores on the measures they report. A plan is considered to have partial data if it submits HEDIS and CAHPS measure data for public reporting, but has insufficient data for one or more measures, submits HEDIS data for public reporting but does not submit CAHPS data, or vice versa, or earned NCQA Accreditation without HEDIS data (health plan accreditation standards only) and did not submit HEDIS or CAHPS data for public reporting.

No Data Reported: Plans that submit results but do not report data publicly, or plans that report no HEDIS, CAHPS or accreditation information to NCQA, are given a rating status of “No Data Reported”.

Insufficient Data: Plan has “missing values” (i.e., NA or NB) in more than 50 percent of the weight of the measures used in the methodology.

Sample Letter: Enlisting Patients Assistance for Claims Payment

Enlisting patient assistance in health insurance claims payment issues.

Date

_____________
_____________
_____________
_____________

RE: Outstanding Health Insurance Payment  

Dear Patient:

I am writing you concerning an issue that has arisen between [ patient’s insurance carrier ] and our office concerning payment for the services provided to you on [ date of service ].”   We have made all reasonable attempts to collect from your insurance company and have not been successful.

PATIENT MESSAGING


[Explain the reason the plan has given for not paying you, or not paying you on time. Stick to the facts. Tell the patient you’re puzzled by the plan’s contention, and that you would appreciate their help in resolving any issues. If the plan’s policy is that the patient is ultimately responsible for the full cost of care, state that.]


We would appreciate your assistance in resolving this matter by:

  • Calling your insurance company directly and asking that the claim in question be paid immediately; and,
  • By asking your employer’s human resources staff to intervene.

Should you or your employer have any questions, please do not hesitate to contact our office at [practice contact and telephone number].

Thank you very much for your assistance and we appreciate your continued business.

Sincerely,

c: [ Name of Insurance Carrier ]

E&M Coding Advice: Simplified

E&M Coding Advice
Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedu

Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.

The Carenodes medical executives offer the following highly simplified but useful “bottom-line” E&M coding advice.

Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded.

  • Do not consider reporting the highest two codes of any code family:

  • When fewer than three distinct medical conditions/complaints  were evaluated and managed during the encounter,
    OR
  • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter. 

  • Do not consider reporting the highest codes of any code family:

  • When fewer than four distinct medical conditions/complaints  were evaluated and managed during the encounter,
    OR
  • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter. 

This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that – by their clinical nature – usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.

Documentation and Billing of Mental Health Services: Incident – to Billing

BY CARENODES ACADEMY

Lines of Business: Medicare, (some private payers)

Certain services provided by your employee (or a fellow employee) may also be eligible for Medicare payment, but check your state law for exceptions and requirements.

“Incident to” Services

Certain services provided by your employee (or a fellow employee) may also be eligible for Medicare payment, but check your state law for exceptions and requirements.

Medicare allows for the billing of “incident to” services performed by ancillary personnel under the supervision of a qualified Medicare provider. Services furnished “incident to” a psychologist’s services are covered by Medicare if they meet specified requirements outlined in the Medicare Carriers Manual. These requirements state that the services must be: 

Service Requirements to Bill

  • Mental health services that are commonly furnished in a psychologist’s office.
  • An integral, although incidental, part of the professional services performed by the psychologist.
  • Performed under the direct personal supervision of the psychologist.
  • Either furnished without charge or included in the psychologist’s bill.  

Psychologists should closely review their MAC’s local coverage determinations (LCDs) for any limitations or restrictions on “incident to” services. You can view the LCDs online.

Medicare allows for the billing of “incident to” services performed by ancillary personnel under the supervision of a qualified Medicare provider. Services furnished “incident to” a psychologist’s services are covered by Medicare if they meet specified requirements outlined in the Medicare Carriers Manual. These requirements state that the services must be: 

  • Mental health services that are commonly furnished in a psychologist’s office.
  • An integral, although incidental, part of the professional services performed by the psychologist.
  • Performed under the direct personal supervision of the psychologist.
  • Either furnished without charge or included in the psychologist’s bill.  

Psychologists should closely review their MAC’s local coverage determinations (LCDs) for any limitations or restrictions on “incident to” services. You can view the LCDs online.

The concept of “incident to” billing, used under Medicare Part B and sometimes adopted by private commercial third-party payers, is complicated to understand and challenging to implement for behavioral health organizations given the diversity of practitioners rendering services.

For behavioral health providers, “incident to” is an attractive option because it increases patient access to services since practitioners without a Medicare billing number, or who are not recognized by Medicare, but also not excluded, can provide care and bill under the supervising physician. The organization is then reimbursed at 100% of the physician fee schedule, as long as the guidelines are followed. 

Having auxiliary staff render services and the ability to bill them as if they were rendered by the physician is a privilege granted by Medicare that requires a thorough understanding of the “incident to” rules. 

This “incident to” fact sheet seeks to clarify the scope and limitations of “incident to” under Medicare as it pertains to mental health services. The intent is to assist providers and organizations avoid compliance pitfalls in the execution of “incident to” billing.

DEFINITION OF “INCIDENT TO” 

“Incident to” means services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services.

The Centers for Medicare and Medicaid Services (CMS) does not provide an explicit definition of “integral, although incidental,” in its extensive description of “incident to” rules. In brief, services that would normally be part of the treatment of a patient by a physician are rendered by an auxiliary person, functioning under the direct on-premise supervision of a physician. These services are integral to implementing the physician’s established plan of treatment of an injury or illness.

WHO MAY RENDER SERVICES “INCIDENT TO” A PHYSICIAN 

Mental health services rendered “incident to” a physician’s professional services are performed by auxiliary personnel such as nurses (RN or LPN) and professional clinicians not recognized by Medicare such as licensed professional counselors (LPCs) and marriage and family therapists (MFTs). Certain non-physician practitioners (NPP) also provide services under “incident to” such as a physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse-midwife (CNM), licensed clinical psychologist (CP) and licensed clinical social worker (LCSW).

A word of caution; there is Medicare language that appears to support that certain NPPs such as NPs, PAs and CPs can also initiate care and have services rendered and billed under their supervision. Per a Medicare Med Learn Matters Article:

“Incident to” services are also relevant to services supervised by certain nonphysician practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives or clinical psychologists. These services are subject to the same requirements as physician-supervised services. Remember that ‘incident services’ supervised by non-physician practitioners are reimbursed at 85% of the physician fee schedule. For clarity’s sake, this article will refer to ‘physician’ services as inclusive of non-physician practitioners

Be aware that NPPs may be prohibited from delegating performance of their services to auxiliary personnel under their respective state licensure laws. The Social Security Act (SSA) also requires that auxiliary personnel providing services “incident to,” must meet “any applicable requirements to provide ‘incident to’ services, including licensure, imposed by the state in which the services are being furnished

KEY COMPONENTS – OUTPATIENT OFFICE/NON-INSTITUTIONAL SETTING

To appropriately bill and receive 100% of the physician payment under the Medicare Physician Fee Schedule (MPFS) in the outpatient office/non-hospital-based setting for mental health services, the following must occur:

  1. The physician, (typically a psychiatrist), must initiate the course of treatment (direct, personal, professional service).5
    • Physicians must see all new patients, whether self-referred or sent for consultation. This allows them to establish a plan of care or treatment for each problem identified. 
    • The initial visit by the physician may be done via telemedicine, assuming applicable Medicare rules are followed in the delivery of telemedicine. Documentation must reflect that it was a telemedicine visit and involved face-to-face contact with the patient.
  1. Because “incident to” is “problem-centric,” if an established patient presents a new problem that results in a change in the plan of treatment, the physician must be involved to initiate the change in care. 
    • EXAMPLE: The supervising physician on-site must be contacted by the NPP or must see the patient to approve the change(s) for the new problem; this contact is documented by the NPP and/or physician. 
      • Because billing “incident to” requires direct, on-site supervision, contact with the physician in this scenario cannot be done via telemedicine or phone consultation. 
  1. Medicare is not prescriptive regarding what a “change” in a plan of treatment entails, so it will be important for organizations to establish the type of changes requiring physician involvement; e.g., a NP wants to prescribe a different medication for a patient or a LCSW decides their patient would benefit from eye movement desensitization and reprocessing (EMDR) to help treat a history of trauma.
  1. There must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.
    • Examples to support physician active participation could include:
      • Documentation of face-to-face visits (can include telemedicine) with the physician as needed, notation made by a non-physician clinician that the case was discussed with the physician, and physician review and signature on the individualized plan of care.
  2. In the office setting, qualifying “incident to” services must be provided by personnel whom you directly supervise, and who represents a direct financial expense to you (such as a “W-2” or leased employee, or an independent contractor).
  3. Direct physician supervision of the NPP or auxiliary personnel is required. 
    • Physician must be present in the office suite (not necessarily in same room).
    • Physician must be immediately available. Per the Centers for Medicare & Medicaid Services (CMS):

Immediate availability requires the immediate physical presence of the supervisory physician. CMS has not specifically defined the word ‘immediate’ in terms of time or distance; however, an example of a lack of immediate availability would be situations where the supervisory physician is performing another procedure or service that he or she could not interrupt. 

SOLO PRACTITIONERS

If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office to supervise.

Documentation practices that will support the appropriate rendering of “incident to” services are as follows: 

  • Evidence of required direct supervision of the services rendered, e.g., statement by therapist on a progress note such as “Therapy rendered today under the supervision of Dr. ______, who was on-site.” 
  • Individualized treatment plans that are reviewed per state requirements, signed and dated by a physician. 
  • Physician order or physician intent documented for nurse visits and patient injections. 
  • When a patient is seen by an NPP or auxiliary personnel and the patient presents with a new problem, the documentation supports that the physician was contacted regarding the new problem and determines the new course of treatment or the patient is seen by the physician prior to initiating a new course of treatment for that problem

APPLICATION & CASES

SCENARIO 1: The psychiatrist performs the initial psychiatric evaluation of the patient and develops a plan of care that includes medication management and psychotherapy. Patient is diagnosed with depression and anxiety and prescribed Zoloft 50 mg. daily. The patient is then seen monthly by a NP who makes no adjustments in the medication. A supervising psychiatrist is on-site during each appointment. 

Assuming all criteria under “incident to” are met, these visits by the NP can be billed under the name/NPI of the supervising physician.

SCENARIO 2: The psychiatrist performs the initial psychiatric evaluation of the patient and develops a plan of care that includes medication management and psychotherapy. Patient is diagnosed with depression and anxiety and prescribed Zoloft 50 mg. daily. The patient is then seen monthly by a NP. At the third visit, based on the NP’s assessment of worsening symptoms, the NP decides a change to Lexapro should be considered. The NP has a hallway discussion with the supervising psychiatrist who is on-site. The physician makes the decision to change to Lexapro. The NP documents the revised order by the physician. 

In this scenario, the NP determines that a change in the initial plan of care is potentially appropriate regarding the medication change. Because the physician made the ultimate decision, this visit and future visits can be billed under the name/NPI of the supervising physician since the plan of care remained the product of the physician’s decision-making

SCENARIO 3: Patient is seen weekly for psychotherapy by an LCSW. The patient calls requesting an additional appointment which the LCSW can accommodate. When the patient comes for this appointment, there is no supervising psychiatrist on-site. 

The visit must be billed under the name/NPI of the LCSW and will be reimbursed at 85% of the physician fee schedule.

SCENARIO 4: Patient is seen for an initial psychiatric evaluation by the psychiatrist. The patient is diagnosed with depression and post-traumatic stress disorder. The initial plan of care includes medication management and psychotherapy. 

The patient is seen for weekly psychotherapy by an LPC. 

During one session, there is no supervising psychiatrist on-site. This visit is not billable as the LPC is not recognized by Medicare and does not have an NPI.  

COMPLIANCE TIPS 

Although “incident to” is a Medicare concept, non-Medicare payers may or may not follow Medicare’s rules for “incident to.” Be sure to contact your Medicaid and third-party payers regarding their rules for billing incident-to services and have their position in writing.

  • Some confusion arises in that many people use the phrase “incident to” to describe billing NPPs or other people qualifying as “auxiliary personnel” under the physician’s billing number for private insurers. Since some private insurers do not give NPPs billing numbers, they instruct the practices/clinics to bill for the NPP services under the physician’s number

MEDICARE RESOURCES

  1. Medicare Benefit Policy Manual. Chapter 15, §60 – 60.4. This describes Medicare rules for the provision of services rendered “incident to” in office, clinic and hospital-based settings.
  2. Medicare Benefit Policy Manual. Chapter 6, §20.5.2. This comprehensively describes coverage of outpatient, hospital based therapeutic services when rendered “incident to” a physician’s service.
  3. Medicare Benefit Policy Manual. Chapter 6, §70 -70.3. This section describes coverage, supervision and documentation requirements for hospital based, outpatient psychiatric services.
  4. Med Learn Matters. Article Number SE0441. Effective August 23, 2016. This article details rules for “incident to” with additional clarifications.
  5. Med Learn Matters. Article Number SE0816. Revised May 22, 2018. This article provides an excellent summary explaining Medicare guidelines for payment of Part B mental health services.
  6. Medicare Learning Network; MLN Booklet. Telehealth Services. January 2019. This publication addresses the core Medicare requirements in the delivery of telehealth services.
  7. Code of Federal Regulations. 42 CFR 410.26. This section of the Federal Code describes the rules of “incident to” and provides definitions of key terms such as auxiliary personnel, direct and general supervision, practitioner and services and supplies.
  8. Code of Federal Regulations. 42 CFR 410.71; 410.73-410.76. These portions of the Federal Code describe Medicare coverage of services to include qualifications rendered by clinical psychologists, clinical social
    workers, physician assistants, nurse practitioners and clinical nurse specialists. The rendering of services “incident to” a physician is also addressed under each section of the respective practitioner.
  9. CMS. CY 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1717-FC), November 1, 2019. This link will go directly to the 2020 final
    rule. Of interest is Section X. (A) – Proposed Changes in the Level of Supervision of Outpatient Therapeutic Services in Hospitals and Critical Access Hospitals where the change is noted to general supervision for
    most hospital-based outpatient services. https://www.federalregister.gov/d/2019-24138/p-97

DISCLAIMER: The information presented in this document should not be considered legal advice; instead, all information, content and material presented in this publication is for general informational purposes only. Readers of this publication should contact their attorney to obtain advice with respect to any particular legal matter.