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Case Study: A Partnership to Address Telehealth Billing Changes

As a result of the COVID-19 pandemic, payors throughout the healthcare industry have modified and/or added numerous coding and billing regulations to reflect changes with utilization, practice patterns and overall healthcare delivery.  These changes enabled healthcare providers to receive additional reimbursement for a variety of telehealth and telemedicine services.  CBIZ KA Consulting Services (CBIZ) has worked with a number of our clients to help them accurately code and bill for these augmented services.  In this article, we highlight how we partnered with a client to develop their telehealth physician education plan and operationalize their provider coding and billing processes to reflect the new telehealth/telemedicine regulations.

On March 31st of this year, the Centers for Medicare and Medicaid (CMS) provided expanded telehealth codes to reflect the changes in healthcare delivery resulting from COVID-19.  These codes provided expanded reimbursement for telehealth in areas such as emergency room, critical care, observation, inpatient hospital care and others.

Initially, the new regulations generated an overwhelming volume of questions from the physician practice group as to the appropriate utilization of these codes.  But instead of answering physician concerns in a piecemeal fashion, we worked with our client’s management team to create a more comprehensive approach to address these issues and other telehealth-related concerns.  As a result, we created a telehealth coding and billing working group, which would research, educate, operationalize and audit new telehealth/telemedicine activity for the physician practice group.  The eight-person working group consisted of the director of physician services, the director of pediatrics, senior internal auditors, physician services managers, and CBIZ staff.

The first order of business for the working group was to create a telehealth education manual and repository for the physician practices.  Combining information from regulatory releases and webinars, proprietary interviews with industry leaders and experts, and our own coding and billing expertise, we drafted an education manual that provided updated regulations from each payor, and, just as importantly, expert interpretation of how physicians should be appropriately utilizing the new codes and billing procedures.  We distributed the educational manual to all members of the physician group.  We then instituted an email chain for physician telehealth questions and created a systematic approach to answering these queries; we also disseminated relevant information discovered in the Q&A to all providers.

A large part of the success of our education and training program has been the setting of expectations that telehealth and telemedicine regulations continue to be fluid and will vary from payor to payor.  Throughout our education efforts, we informed providers that there were pivotal areas of billing and reimbursement left unaddressed by various payors.  As new information becomes available, we update the manual and training materials, and reiterate with physicians that specific gray areas still exist within the new guidelines from various payors.  Ultimately, we have created an understanding that compliant billing and coding practices will continue to evolve throughout this process.

The next component in tackling the new regulations was to help implement and standardize practices within the physician group.  Significant changes were required to update the revenue cycle I.T. system to ensure that new codes were added to the system.  We facilitated discussions with the operations manager and a senior I.T. manager where we provided a list of telehealth additions that needed to be made to the existing billing system. By explaining the urgent need for these changes, the new codes and layout of corresponding screens were updated quickly and painlessly.

Another key component of our implementation strategy with the client was the auditing of accounts that featured the new telehealth changes.  All parties expressed concern that with the rapid introduction of new coding and billing practices, sub-optimal compliance and reimbursement could result. Immediately following the dissemination of our training manual, CBIZ began a chart review process to ensure that documentation met the CPT codes that were being billed. In the initial ramp-up period, we were reviewing scores of charts on a daily basis, and now we are still auditing 20-25 charts per day.  When major changes occur with new telehealth regulations, we increase the number of charts we audit to ensure that providers were adhering to new guidelines.  As part of our audit process, if we identify specific physicians with aberrant or non-compliant coding or billing, we provide individualized provider education to improve performance.

CBIZ has made substantial progress with our client in getting clean claims out the door that are compliant. However, we still face several challenges.  We continue to have discussions with our client about place of service decisions and the appropriate utilization of modifiers, which can lead to significantly different reimbursement rates and cost-sharing responsibility for patients.

In addition, we continue to receive new regulations and guidance from payors regarding how they will reimburse for telehealth and telemedicine services.  These updates at times can provide needed clarification regarding acceptable practices.  But we have found that many payors have yet to address a number of important telehealth billing and coding questions, in particular for areas of preventive medicine.  Many payors have taken their direction from CMS, but not all, and others have created different telehealth coding and billing guidance than CMS’s.  As a result, we continue to have frequent educational updates for our providers and clinical staff, which, unfortunately, still include a number of billing and coding gray areas.

Overall, our work with the client has helped them navigate a vast patchwork of new telehealth coding and billing guidelines to create a coherent process that has implemented and operationalized new practices.  Through a systematic approach to addressing the new regulations, we have standardized provider education throughout the physician group, and created best practices that ensure compliance and optimal reimbursement.  Work continues; we still face many challenges; but we have made great progress. 

For any questions or for information on how CBIZ can assist during this transition period, please contact Adam Abramowitz at 609-220-5627 or at aabramowitz@cbiz.com.

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