As 2019 draws to a close, this author is going to answer frequently asked questions (FAQs) that readers submitted on a variety of reimbursement topics. If you enjoy reading these FAQs, continue to submit your questions, and they will either be answered as a featured topic or in an FAQ column like this one.
Q: Now that the new skilled nursing facility (SNF) payment system is in place, has consolidated billing (CB) gone away?
A: The SNF CB requirements still exist in the new Patient Driven Payment Model that was implemented on October 1, 2019. Only services that are excluded from the CB provision will be paid by Medicare to providers other than SNFs. The CMS periodically updates the lists of Healthcare Common Procedure Coding System codes that are excluded from the CB provision. For nontherapy services, SNF CB applies only when the services are furnished to an SNF resident during a covered Part A stay. For therapy services, SNF CB applies whenever they are furnished to an SNF resident, regardless of whether Part A covers the stay.
The CMS maintains four files to assist SNFs and other providers in identifying services that are/are not included in CB. The first three files are for services provided to beneficiaries in a Part A-covered SNF stay. Files 1 and 2 list codes that can be separately billed to the Part B Medicare Administrative Contractor (MAC) by physicians, nonphysician practitioners, and suppliers (other than ambulance suppliers). If a code is not found in either of these two files, the service is subject to SNF CB, and the physician, nonphysician practitioner, or supplier must look to the SNF for payment of the service. The Part B MAC will not pay for the service. For example, selective debridement codes (97597-97598) are not listed in either File 1 or 2. Therefore, these services are subject to the SNF CB.
File 3 does not pertain to wound management professionals; it pertains only to ambulance services. File 4 includes the therapy codes that are subject to SNF CB for beneficiaries in both a Part A-covered stay and a noncovered stay. The physician, nonphysician practitioner, or supplier must look to the SNF for payment of these services. The Part B MAC will not pay for these services. For example, negative-pressure wound therapy with disposable equipment (97607-97608) is not listed in File 4. Therefore, this service is not subject to the SNF CB.
The CMS periodically updates the four files to correct errors and include newly developed procedure and supply codes.1
NOTE: In the October 1, 2019 update to the SNF CB, providers were alerted that the application of Unna Boots (29580) and the application of multilayer compression bandages (29581 and 29584) were incorrectly listed in File 1. Effective October 1, 2019, these three codes were removed from File 1 and added to File 4 and are now subject to SNF CB. Therefore, wound/ulcer management professionals and providers who provide these compression procedures for SNF patients will no longer receive payment for them from their respective MAC. Instead they must have a contract with the SNF that allows them to bill the SNF for these procedures.
Q: I thought that Medicare did not pay for telehealth for patients in their homes, but some of my colleagues are telling me that physicians are paid for in-home services they call "remote evaluations" and "virtual check-ins." Is this correct?
A: You are correct that the originating site for telehealth services cannot be the patient's home. Medicare has strict regulations surrounding telehealth services, including originating sites such as physician offices, critical access hospitals, and SNFs.2 However, your colleagues are also correct. Effective January 1, 2019, the CMS created some new codes for physicians and other qualified healthcare professionals (QHPs) who are eligible to perform evaluation and management services:
G2010 Remote evaluation of recorded video and/or images submitted by an established patient (eg, store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment
G2012 Brief communication technology-based service, eg, virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
Although these new technology-based codes do not have the same regulations as the telehealth codes, the CMS released specific regulations that pertain to them. For example, both codes require verbal or written/electronic patient consent before each service is provided. "Blanket" consents are not acceptable. The physician/QHP must inform the patient that the Medicare program and the patient will be charged for the service.
Some of the regulations for the remote evaluations are as follows:
* The physician/QHP must document the (1) patient's consent, (2) review and interpretation of images, (3) date and time of beneficiary contact, and (4) content of discussion with the patient.
* If the media is compliant with the Health Insurance Portability and Accountability Act, the follow-up by the physician/QHP may be via phone, audio/video, secure text messaging, or email.
* The quality of the images must be adequate for the physician/QHP to assess the need for medical treatment.
Some of the regulations for the virtual check-ins are as follows:
* The virtual check-in must be initiated by the patient.
* The virtual check-in must be a real-time, two-way audio and/or video conversation. It cannot be a voice message.
* The virtual check-in must be medically necessary.
* Calls by the physician's/QHP's clinical office staff do not qualify for use of G2012.
Q: Some physicians/QHPs told me that they began making home visits in 2019 to manage chronic ulcers of Medicare beneficiaries. I thought it was difficult to justify the necessity of a home visit to Medicare. Has there been some change?
A: Yes, effective January 1, 2019, the CMS removed the need to justify providing a home visit instead of an office visit. Chapter 12 of the Medicare Claims Processing Manual3 revised its language about home visits. The manual now states that "Home services codes 99341-99450 are paid when they are billed to report evaluation and management services provided in private residences." In addition to a private residence, "home" may now also include temporary lodging or short-term accommodations such as hotels, campgrounds, hostels, or cruise ships.
Some of the CMS regulations for these home visits are as follows:
* The physician/QHP must have a face-to-face visit with the patient.
* The place of service reported on the claim must be place of service 12 home.
* "Incident-to" billing is not appropriate. If a QHP provides the home visit, the QHP must use her/his own provider number on the claim.
* The physician/QHP cannot use office visit codes 99201-99215 when reporting home visits.
Q: Some of my peers say they are being paid to consult with physicians who do not have chronic ulcer management experience. Is Medicare really paying for this type of consultation?
A: Yes, your peers are correct; they can now provide technology-based interprofessional consultations. In fact, the physician/QHP who requested the consultation can also be paid for the time spent preparing for the consultation, as well as the technology-based interprofessional consultation. The appropriate code for the requesting physician/QHP to use is 99452. Some of the CMS regulations for this code are as follows:
* This code only payable is to physicians/QHPs who are eligible to bill for E/M services.
* The patient should be informed that she/he will incur a copayment for this service and must provide verbal consent.
* The patient's verbal consent and the requesting physician's discussion with the consultant must be documented in the medical record.
* Because this is a time-based code, the treating/requesting physician/QHP must spend 16 to 30 minutes preparing for the referral and/or communicating with the consultant.
* This code should be reported only once in a 14-day period.
The appropriate code for the physician/QHP who provides the requested interprofessional consultation is 99451.
Some of the CMS regulations for this code are as follows:
* If the consultation is less than 5 minutes, this code should not be reported.
* If the sole purpose of the communication is to arrange a transfer of care or other face-to-face service, this code should not be reported.
* This code is payable only to physicians/QHPs who are eligible to bill for E/M services.
* The patient's verbal consent, time spent with the requesting physician/QHP, topic, and summary of recommendations must be documented in the medical record.
* This time-based code requires a written report to the requesting physician/QHP.
* The service time is based on total review of medical records, laboratory and imaging studies, medication profile, pathology specimens, and the interprofessional communication time.
If the interprofessional consultation includes both a verbal and a written report, use codes 99446 through 99449. Some of the CMS regulations for these codes are as follows:
* If the consultation is less than 5 minutes, these codes should not be reported.
* The consulting physician/QHP may only report these codes if the consultation concludes with a verbal opinion report and a written report to the treating/requesting physician/QHP.
* The consulting physician/QHP may not report these codes if she/he has seen the patient within the last 14 days or when the consult leads to a transfer or care or other face-to-face service by the consultant within the next 14 days.
* Most of the service time reported (>50%) must be devoted to the medical consultative verbal and/or internet discussion.
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