What Rural Health Clinics Need to Know About Telehealth Billing

April 21, 2020 | Article

By Deyon Suchla

The CARES Act authorized rural health clinics (RHCs) to furnish telehealth services and bill as the distant site provider during the COVID-19 Public Health Emergency. Providers can perform these services from any location, including their home, during times when they would have otherwise been regularly scheduled to see patients in the RHC.

Update to MLN Matters Number SE20016
CMS has released an update to MLN Matters Number: SE20016 (Revised 04/30/2020) providing new instruction for billing of RHC Telehealth services.

Effective 03/06/2020 through 06/30/2020

  • Beginning date of RHC eligibility to bill as distant site provider with patient in their home.
  • Bill with HCPCS code G2025 for all covered telehealth services.
  • Append the CG modifier (no 95 modifier required).
  • Initial payment will be your AIR amount through July 1 when MACs will automatically reprocess claims to pay at the new rate.
    • Coinsurance assigned based on charged amount associated with CG modifier line.
  • New rate of $92.03 is the average amount for all PFS telehealth services on the telehealth list (weighted by volume).

Note: If you previously submitted claims for services that met the definition of 99441 to 99443, we recommend you submit an adjusted claim using G2025 with CG modifier.

07/01/2020 through end COVID-19 PHE

  • Bill the HCPCS code G2025
  • No modifier CG is reported
  • Paid at PFS amount of $92.03 (if PHE extends into 2021, amount will be updated).
    • Coinsurance assessed will be 20% of $92.03 allowed amount or $18.41.

Additional Covered Services
RHCs are allowed to furnish any telehealth service that is approved by Medicare under the PFS list of services which includes telephone services.

  • Audio-only telephone E/M service codes 99441, 99442 and 99443 are now covered
  • Bill with HCPCS G2025
  • Reimbursement will be AIR amount through July 1 when claims will automatically be reprocessed by the MAC and reprocessed at the $92.03 rate.
  • Must provide at least 5 minutes of telephone E/M.
  • Call can not be related to an E/M service provided within the previous 7 days or lead to an E/M service or procedure within the next 24 hours or soonest available appointment.

How to Ensure Appropriate Billing for Services
Effective 01-27-2020 through 06/30/2020:

  • Billing will remain on the UB-04 with the appropriate E/M code and 95 modifier appended to indicate the encounter was not a face-to-face visit, but rather services were provided using telehealth connection between the provider and patient.
    • These claims will initially be paid the all-inclusive rate (AIR), but then will be automatically reprocessed beginning July 1 to adjust initial payment to the $92 limiting amount established by CMS. This rate is based on the national average of allowed telehealth services and is the same amount for all RHCs.
    • Medicare will pay 80% ($73.60) leaving the 20% coinsurance of $18.40.
    • The CS modifier is appended if the visit resulted in the ordering of a COVID-19 test.
    • The CS modifier is to process at 100% Medicare payment (no deductible/coinsurance due from the patient nor should any be collected).
      • The MACs will not be able to meet this requirement until the July (next CMS quarter) update is released so these claims also will be reprocessed beginning July 1.
      • Since they will initially process leaving a 20% deductible/coinsurance amount, expect refunds to secondary payers once the claims are reprocessed at 100%.
  • The G0071 Virtual Communication Code has been expanded to include services defined under 99421, 99422 and 99423 in addition to the G2010 and G2012 which has been in effect for RHCs since 1/1/19.

Effective 07/01/20:

  • RHC telehealth services will be billed with code G2025 which will process at the $92 national average allowed amount.
  • No direction has been given regarding use of modifiers for this fee-for-service (FFS) codes.

Here’s what you need to know about Medical Procedure Codes and COVID-19.

What was not addressed:

  • Instructions related to the CG modifier.
    • This is important as we know that this modifier is what prompts the AIR to be paid and without it claims get held up in the Medicare system and will not process for payment.
    • CMS has indicated to the NARHC (per notice on their website April 21, 2020) that the CG is to be on the claim; however, printed instruction has not been released.

What to Do After July 1, 2020
Telehealth Claims
If your AIR rates differs from the $92 FFS rate established for RHC telehealth claims, when MACs reprocess claims after July 1, 2020, the deductible/coinsurance amounts will change.

Claims Processes

  • Be prepared to cancel secondary payer claims that automatically crossed over and resubmit with the new Medicare payment information.
  • If the secondary did not automatically cross over, hold the claim until a time when it is reprocessed by Medicare for the correct amount so as to not duplicate efforts.
  • Implement process for refunding patients that do not have a secondary payer.

Receivable/Payable: Between Start Date of Delivery of Service and June 30, 2020

  • If the AIR is above the $92, determine the liability for a payback to Medicare for the difference between the AIR and the $92.
  • If the AIR is below the $92 amount, establish a receivable the facility expects to receive on the difference on those claims.

CS Modifier
Claims submitted with the CS modifier (indicates telehealth services resulted in COVID-19 testing) are to be paid at 100%. MACs will not be able to pay these claims at 100% until the July 1, 2020, CMS update is released. From now until June 30, 2020, they will pay at 80%, leaving the patient responsibility of 20%.

Claims Processes

  • Secondary cross-over claims will need to be refunded once the 100% payment is reprocessed.
  • Implement process to not bill patient coinsurance on these claims if there is no secondary payer.

Remittance Advice Remark Code (RARC)
These codes are in addition to the Claim Adjustment Reason Code (CARC) to provide further information on denied services reported on the payer explanation of benefits. Because RHCs haven’t previously billed as a distant site provider, you may not be familiar with this code in the event the billed telehealth services are denied. As a reminder, N776 is not a covered Telehealth service.

The Impact of Telehealth Services on Cost Reporting
Since the telehealth services rendered by RHC practitioners will not be paid the AIR but on a blended fee schedule amount, the associated costs of furnishing the telehealth services will not be used in calculating the AIR on the Medicare cost report.

  • RHCs should appropriately track the costs of providing both originating and distant site telehealth services in order to properly report these services on the Medicare cost report.
  • In addition, we recommend tracking the time spent providing distant site telehealth services in order to exclude these hours from the calculation of the FTE when calculating the productivity standards.

What RHCs Need to Consider When It Comes to Telehealth Services and Billing
RHCs have been given the green light to provide telehealth services as a distant site provider. CMS has issued the guidelines to enable the billing for these services, which will require changes to current processes. Facilities need to:

  • Set up the billing for the services appropriately
  • Manage the reprocessing of the claims
  • Ensure appropriate handling of the secondary insurances and refunds made as applicable
  • Estimate due to/due from for the payment differential
  • Establish tracking for cost reporting purposes

The CARES Act has allowed this provision of care to further maintain the safety of the patient and the healthcare provider. It does not come without its challenges and complexities with coding, billing, cost reporting and accounting. This further supports the establishment of well documented policies and procedures on how an organization is addressing the RHC Telehealth service implementation.

Here’s what it takes to provide telemedicine support during COVID-19.

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