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    Welcome to the ClaimCare Medical Billing Blog. We strive to provide content that improves the overall quality of medical billing efforts across the US. If you have any specific topics that you would like to see addressed in this medical billing blog please post the topic in the Medical Billing Questions & Answers Forum. If you have an article that you would like considered for publication in the medical billing blog then please email your article to resources@claimcare.net.

    MEDICAL BILLING BLOG

    What Does Today's (5/11/2023) End of the COVID PHE Mean for Providers?

    Posted by Carl Mays, ClaimCare President/CEO on Thu, May 11, 2023 @ 02:02 PM

    Medical Billing ExpertsThe Biden Administration is ending the COVID19 Public Health Emergency May 11, 2023. This blog is intended to assist you with that transition which includes important coding andImpact of the Proposed 2019 Medicare to the Medical Billing of Ambulatory Surgical Center Services billing items that will change because of the end of the PHE. Even if you believe that you are no longer involved in the treatment of or diagnostics for COVID, if you are doing any kind of remote patient care, laboratory, or Telemedicine then you will need this information moving forward. It is hard for a medical provider to be Medical Billing Experts on all relevant topics. ClaimCare is here to help. 

    ClaimCare Medical Billing Services has remained diligent in our billing efforts, compliance efforts, and client direction, to ensure that our clients have been reimbursed the maximum amount allowable. At the beginning of the Pandemic, we encouraged all of our clients to perform eligibility prior to services being rendered. That process should remain in place. Eligibility issues will continue to be a priority, so we encourage you to monitor that process going forward and ensure it is being fully utilized in your workflow.

    Major bullet points that will impact your practice and/or COVID related business going forward:

    • Telehealth Services
      • Telehealth services will continue to be allowed through the end of 2023. CMS expects to continue this service to Medicare Recipients as it has proven to enhance patient outcomes. Providers should continue to use CPT codes as if they were in person visits with modifier 95 to indicate services were delivered via telehealth.
      • Telehealth does NOT require video beyond the pandemic if the patient does not have a smart phone or computer.
    • COVID Treatment
      • COVID Vaccines are still covered 100% with no patient co-insurance/deductible. Do NOT use the CR modifier after May 11th.
      • COVID Booster still covered 100% with no patient co-insurance/deductible. Do NOT use the CR modifier after May 11th.
      • Treatment via oral anti-viral will continue to be covered without patient co-insurance after May 11th Do NOT use the CR modifier after May 11th.
      • Private Insurance is required to cover Vaccines and treatment for COVID19 with no co-insurance. Do NOT use the CR modifier after May 11th.
      • Diagnosis coding for COVID related services should still utilize ICD-10 Z20822
    • COVID Testing
      • After May 11th, all testing must be ordered by a physician or other eligible provider.
      • Lab U0003, U0004, and U0005 will not be covered beyond May 11th. Revert to the usual PCR testing. You should choose the test that best describes the actual test you run.
        • Most Labs do not report a range (quantitative results) It is typically reported as a positive or negative. In this instance, it is recommended that you choose 86413 if you DO report quantitative results. If you do NOT report quantitative result, choose 86769. (this is for PCR testing only) Refer to the actual lab test that you report on to choose the closest CPT code for the test you bill.
      • Labs are no longer required to report to CDC after May 11th.
      • Labs are no longer required to post prices on their website for price transparency beyond May 11th.
      • G2023 and G2024 will no longer be covered (lab specimen collection) beyond May 11th.
      • 99211 will no longer be utilized for specimen collection beyond May 11th.
      • Over the Counter COVID Tests will no longer be covered beyond May 11th except for Medicaid plans. Medicaid plan members will be able to obtain OTC COVID tests through December 2023.
    • Miscellaneous
      • Virtual Supervision stays in effect through the end of 2023.

    Please reach out to the ClaimCare team if you have any questions.

    ClaimCare has 30 years of medical billing experience. We have an established 100% USA-Based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients.

    ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2021-2022 recognition. 

    For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete credentialing processing.

    Tags: CMS Update, telemedicine, Center for Medicare and Medicaid Services, CARES Act, COVID

    Reminder: COVID-19 Testing Coverage Expands

    Posted by Carl Mays, ClaimCare President/CEO on Tue, Mar 16, 2021 @ 06:00 AM

    The+Law

    On February 26, 2021, the Centers for Medicare & Medicaid Services (CMS), together with the Department of Labor and Department of the Treasury, issued new GUIDANCE that removes barriers to COVID-19 diagnostic testing and vaccinations, and strengthens requirements that plans and issuers cover diagnostic testing without cost sharing.

    This CMS guidance raises some key points and a few questions that need to be inspected by Healthcare Compliance Attorneys of providers/organizations involved with testing and vaccinations. With this blog post we are providing further details about the CMS guidance and we are highlighting questions that the affected providers/organizations need to have answered by your Healthcare Compliance/Billing Attorney.

    Key Points and questions:

    1. It is critical that individualized medical necessity screens remain in place.
      • This guidance document makes it clear that any testing done without “individualized clinical assessment” would be considered either public health surveillance or a job requirement and would not be required to be paid by insurance companies.
    1. It is critical to get the interpretation of these new guidelines from a healthcare compliance and billing legal expert because there are some unclear areas in the guidelines. Specifically:  
      • On the one hand, the document says that payers cannot deny coverage of a COVID-19 test for lack of medical necessity. On the other hand, they say that payers must assume when they receive a claim that it reflects an "individualized clinical assessment." This seems to imply there has in fact been a medical necessity determination by a medical provider. 
         
        • If an "individualized clinical assessment" does imply the presence of a medical necessity, then how does the example of "I want to be sure I am COVID-19 free before seeing my parents" require such assessments to be modified so that a COVID-19 test is approved for reasons of this nature? 
      • The document seems to emphasize the importance of an individual seeking the test vs the test being required for Public Health Surveillance or employment. How does the distinction between a test being required interact with medical necessity of a test that is determined via an “individualized clinical assessment?” 
        • If I am seeking a test because I need to show clear results to attend an optional event like a ballgame, a concert, a visit to a nursing home, a cruise, etc., then if prior to testing I have an “individualized clinical assessment” (e.g., a screening questionnaire), does that meet the criteria for a billable test since I am seeking the test so that I can attend an optional event AND I am receiving an individualized screening for medical necessity? These examples seem extraordinarily similar to the specific example given by CMS of an asymptomatic person with no know exposure having the COVID-19 test covered because the person wants  to visit a parent or relative.
        • If I need to have a clear test for my job AND I have an individualized medical necessity screen applied, is there any reason that the test cannot be billed to insurance if I show medical necessity through this “individualized clinical assessment?” Prior to this CMS clarification, payers had to cover a COVID-19 test when a medical necessity screen based upon symptoms or potential exposure warranted it. Does the fact that in some situations, such as “I want to visit my parents,” traditional medical necessity based upon symptoms or exposure risk seems to no longer be a requirement mean that a medical necessity screen can no longer be used to justify insurance billing of employee tests justified by exposure or symptoms and ordered via an “individualized clinical assessment?” In other words, has the medical necessity screen lost importance in determining if you can or cannot bill insurance for employees?  
      • Does any of this impact the wording of agreements that might be put in place with organizations requesting testing to help to ensure the language in the agreement does not run afoul of any of the public surveillance and employment testing exclusions?

     More Detail behind the points and questions above:

    There are a few key areas on the CMS guidance document that prompted the questions I outlined above. As you can see on the document, there are 13 questions that are asked and answered. I spotlight Question 2 and the answer supplied by CMS:

    Q2 – May plans and issuers distinguish between COVID-19 diagnostic testing of asymptomatic people that must be covered, and testing for general workplace health and safety, for public health surveillance, or for other purposes not primarily intended for individualized diagnosis or treatment of COVID-19?

    Answer – Yes. Plans and issuers must provide coverage without imposing any cost-sharing requirements (including deductibles, copayments, and coinsurance), prior authorization, or other medical management requirements for COVID-19 diagnostic testing of asymptomatic individuals when the purpose of the testing is for individualized diagnosis or treatment of COVID-19. However, plans and issuers are not required to provide coverage of testing, such as for public health surveillance or employment purposes. But there is also no prohibition or limitation on plans and issuers providing coverage for such tests. Plans and issuers are encouraged to ensure communications about the circumstances in which testing is covered are clear. To the extent not inconsistent with the FFCRA’s prohibition on medical management, plans and issuers may continue to employ programs designed to detect and address fraud and abuse.

    This is the section that prompts the questions about whether “individualized screening” moves a test form the public surveillance realm to the covered test realm. The concern is whether loosening the “medial necessity” guidelines apparently to allow individuals to have covered COVID-19 tests for any reason they deem necessary impacts the weight “individualized screening” has held in relation to COVID-19 testing up to this point in terms of justifying billing based upon medical necessity.

    The answer below to Q1 in the guidance document is what creates the uncertainty between the purpose of “individualized clinical assessment” when reasons such as “visiting my parents” now are covered for testing.

    “When an individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized health care provider, or when a licensed or authorized health care provider refers an individual for a COVID-19 diagnostic test, plans and issuers generally must assume that the receipt of test reflects an  “individualized clinical assessment” and the test should be covered without cost sharing, prior authorization or any other medical management requirements.”

    This statement is also what makes it critical that you have a screening that results in a "yes" where a doctor orders the test or a "no" where a doctor does not order the test. As long as the doctor does not order test for people that do not pass the screen then it should fall under the “individualized clinical assessment” point made above.

    Finally, the document also emphasizes the importance of an “individualized clinical assessment” when it says test must be covered "...when a licensed or authorized healthcare provider administers or has referred a patient for such a test." 

    Conclusion:

    Obviously, this blog post poses more questions than it does clear guidance. However, as has been the case from the beginning of COVID-19, these situations are unprecedented. As such, the devil is in the “legal details.”

    I would argue that all of this guidance means:

    1. Medical necessity is still required,
    2. The scope of medical necessity has expanded, and
    3. As long as an individual screening for medical necessity is used, individuals meeting the new medical necessity guidelines are billable to insurance.

     What is far from clear is exactly how this guidance specifically expands the definition of “medical necessity.”

    Thus, as emphasized in the beginning of this blog post, it is critical to obtain your Healthcare Attorney’s opinion on all the points and questions outlined in this post and in the CMS GUIDANCE document.

     

    About ClaimCare ®                        

    ClaimCare has 30 years of medical billing experience. We have an established 100% USA-Based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients. 

    ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this recognition.

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    For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.

     

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    Tags: medical billing coding, COVID-19, COVID, COVID and the law

    COVID-19 CPT Code Update

    Posted by Carl Mays, ClaimCare President/CEO on Fri, Sep 25, 2020 @ 06:00 AM

    Just in case you are not already aware, this memo is to inform you the American Medical Association (AMA) added Current Procedural Terminology (CPT) code 99072, effective September 8, 2020, and has updated information about this code and other codes, which was posted September 22, 2020, on the AMA website in an article titled COVID-19 Coding and Guidance.

    COVID-19 Update

    Coming rather late in the COVID-19 crisis, this code regards “Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service when performed during a Public Health Emergency as defined by law due to respiratory-transmitted infectious disease.” 

    CPT Code 99072 Explained

    The earlier announcement explained Code 99072 is used to report additional practice expenses necessary in an office visit or other non-facility setting to mitigate the transmission of the respiratory disease for which the Public Health Emergency (PHE) was declared. These expenses include, but are not limited to, additional supplies such as face masks and cleaning supplies, as well as clinical staff time for activities such as pre-visit instructions and office arrival symptom checks that support the safe provision of evaluation, treatment or procedural services during the respiratory infection-focused PHE.

    Instructions state that when reporting 99072, report only once per in-person patient encounter per day, per provider identification number, regardless of the number of services rendered at that encounter. Code 99072 may be reported during a PHE when the additional clinical staff duties as described are performed by the physician or other qualified health care professional in lieu of clinical staff.

    Dollar Value To Be Established

    This new code does not yet have any dollar value associated with it, but efforts are underway to establish payment. 

    CPT Code 86413 Also Approved

    As explained in the update, the AMA also approved CPT code 86413, which regards “Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative," in response to the development of laboratory tests that provide quantitative measurements of SARS-CoV-2 antibodies.

    Per the standard early release delivery process for CPT codes, note that the code descriptor will need to be manually uploaded into electronic health record systems. In addition to the long descriptor, codes 99072 and 86413 have short and medium descriptors that can be accessed on the above mentioned AMA Website.

    For more detailed information on reporting codes 99072 and 86413, please refer to the September Update article on CPT Assistant, the official source for CPT coding guidance.

    _________________________

    About ClaimCare ® 

    ClaimCare has 30 years of medical billing experience. We have an established 100% USA-based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients.

    image-png-1ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2019-2020 recognition.

    For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing. 

    Tags: medical billing coding, COVID-19, COVID

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