If you remember, some of those billing codes are used interchangeably between telehealth and regular office visits. Other codes, like maybe a telephone visit, could be considered telehealth by definition. But how does my insurance know the difference? How does our doctor let our insurance company know the visit was telehealth?

They use a special coding language that only they know.

Until now, that is. Thankfully, Max has decided to decode it. I am risking my life in the name of Max Out of Pocket.

Unfortunately, medical providers and insurance companies do not always speak the same language. This can end up impacting our out-of-pocket costs. To understand how the billing should look on these visit types, we are going to need to brush up on two brief medical billing concepts.

• Place Of Service Codes
• Modifiers

Stay with me here. In just a few short paragraphs of training, we are going to be running circles around billing departments all across the United States. I even have visual aids.

We, as consumers, can correct the system where it needs correction. If you master some of this lingo you will have what you need to go to battle with your clinic or health insurance over incorrect out-of-pocket costs related to telehealth.* Who knows, maybe we have a few doctors reading this that need to go to battle with their own in house coding and billing departments.

Place of Service Codes

The place of service is just what it sounds like. It is where our medical services physically took place. It is a numeric code on your medical claim form that the medical provider puts on there to tell your insurance where the services occurred. In my mind, this is one of the easiest ways for a doctor’s office and insurance company to make sure they have the same understanding of where the services happened.

The place of service has its very own spot on the claim form sent to your insurance company. If you really want to show your billing office you know what you are talking about, tell them it is located on form locator 24b of the 1500 medical claim form. Here is an example of a hypothetical simple ‘evaluation and management’ service that took place in a jail. Yes, jails have their own place of service code, it’s 09.

There is a whole list of possible places of services here.

In general, I would say most medical clinics and commercial insurance use a “place of service” code to represent where the services are happening. For example, if you were physically in the clinic with your doctor and you can reach out and touch them, they will likely use a “place of service” code 11. This represents an office setting. There are, of course, exceptions**, but this is the norm.

Telehealth Place of Service

With telehealth, we are not physically in an office. So ultimately, we are going to want our insurance company to know that. We need a way to let them know the visit was done through telehealth. One way to tell them is by reporting a place of service code 02 on our claim form.

02 Telehealth: The location where health services and health-related services are provided or received, through a telecommunication system.

Fortunately, if our doctor’s office can get this on the claim form correctly, our medical insurance has been officially notified that the services were provided through telehealth. This “02 code” is one way they might know that our out-of-pocket costs should be handled in a certain way. But some payers, like Medicare, want it reported a bit differently.

Modifiers

Billing modifiers are a little harder concept, but I have faith you will understand it. A modifier is a way for your doctor to tell your insurance company that they did a medical service, but there is something weird that the insurance company should know about the service. It is added to the end of your billing code. Here is where it is located on most medical claims.

Telehealth Modifiers

So if your doctor does a simple “evaluation and management” of a problem you are having through telehealth, you are going to want them to flag it accordingly. Some insurance companies will use this modifier when they process your claim so they know to treat out-of-pocket costs differently. It seems to me that the modifier most insurance companies are requesting is “modifier 95”.

Modifier 95: Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System

For those who do not already know, “synchronous” basically means the interaction is happening in real-time. Don’t worry, I had to look it up for context. 

Of course, why not have one modifier when you can have two that make things twice as confusing? Some payers will require modifier GT on the billing code. It basically means the same thing.

Modifier GT: Via interactive audio and video telecommunication systems. Use only when directed by your payer in lieu of modifier 95

These two modifiers are another way your insurance company gets told the services were done through telehealth. They should tell their system to recognize your services were provided through telehealth.

Other Telehealth Scenarios

Modifier GQ: Via asynchronous telecommunications system.

No, I’m not talking about the magazine.

Remember, sometimes we can send photos and recorded videos to our doctor and have them check something out? If you remember, the billing code for this is G2010.

• G2010 represents the remote evaluation of a recorded video and/or images submitted by an established patient

Here is how the claim might look:

Now that you know what “synchronous” means, we get to learn what “asynchronous” means. This refers to two or more events not happening at the same time. Since my doctor is not reviewing my boil in real-time, my insurance company may need to know that. Modifier GQ can make that happen if the code itself isn’t enough for them to understand.

Here’s The Problem

Place of service and modifiers are the primary language medical clinics and insurance companies talk to each other when it comes to telehealth. Unfortunately, it is not necessarily standardized across all payers. United Healthcare may want it one way where Anthem wants it another way. Some just want the modifier, some just want the place of service, and some want both. This is where billing errors occur. Finding someone on either side who can accurately speak this language can be hard.

Do “telephone” visits need the modifier codes? They are technically not “video” so I would not think so. But then again, I know some payers will want it anyway. They likely meet the definition for the place of service 02. There is a lot of room for incorrect interpretation here.

Additionally, if the clinic has a special “designation” from Medicare, like maybe a “Rural Health Center”, there are additional codes we are supposed to use for just Medicare.

Final Thoughts

My goal here is to create an army of informed consumers who can help the system get this right.

With that, we now have a pretty solid understanding of how telehealth billing should look. We understand the place of service, billing codes, and even how those codes can be modified. We can use these tools to talk through potential billing errors that might come up with our insurance claim. With an army of educated consumers, we can start putting pressure on the system where we need to.

Hopefully, your insurance company committed to paying telehealth services for 90 days with no out-of-pocket costs during the 2020 pandemic. It is likely going to be these codes that tell them to make that happen. In some cases, their systems will not be set up quickly enough to keep up with policy changes. In other words, they won’t recognize these codes even with the place of service and modifiers. They may forget to initially waive out-of-pocket costs. Understandable. But here at Max Out of Pocket, we like to follow things through and make sure they are done right.

Have you had any billing errors related to telehealth?

*When Max Out of Pocket readers “battle” with insurance companies and doctor’s offices, we are always firm, but respectful. These people are just doing their jobs. I don’t believe anyone is going out of their way to make our lives difficult. There are worse things in this world than a couple of inconvenient phone calls, so let’s not make more of it than there is. 

**If you are a Medicare patient seeking services from a clinic on a hospital campus, things may be slightly different. If you happen to fit into that scenario, email me and I will walk you through it. The modifiers still come into play, but the place of service isn’t always a thing.

Again, Max is not a “certified coder”, but these concepts are not rocket science if you know where to look. I purposely left a few examples out of this, but if you have one you want me to review, please reach out!

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My state is set to slowly phase-in services starting May 4th. Healthcare is at the top of this list. Treading lightly will be key to our success.

By the same token, I am wondering what parts of our infrastructure have been permanently changed. Are one-way shopping aisles here to stay? Will masking be the new norm as we enter hospitals? Are haircuts a thing of the past? Hopefully, free lunch at my hospital is put into a new policy and procedure.

After a few weeks of adjustment, the Max Out of Pocket crew quickly adapted to the new normal. We have come to enjoy the slower pace of life. We did re-up our meat supply a bit this week after hearing from the Tyson Foods chairman that there may be supply disruptions. Mrs. Max OOP went to the University of Arkansas which isn’t too far from Tyson’s headquarters. She keeps an eye on what they say. We didn’t go crazy or anything, just 5 lbs of beef and a large packet of chicken. You never know. We have been pretty good at spacing out our trip to the store.

With that, welcome to the 9th edition of Max’s Back Pocket.

Max’s Back Pocket

Over the last several years, I have absorbed a ton of great content from a lot of talented people in and around the internet. Several of those ideas even got implemented into my personal finance strategy. Some of these writers are professionals, but a lot of them are just amateurs throwing their weight around in a random niche. I like to think I am pretty good at healthcare and personal finance, but there are plenty of people out there much smarter than me.

Up until now, most of these ideas just landed in my back pocket. There they would sit for my own benefit whenever I needed them. They were rarely shared or exchanged with anyone in my personal network. These days, that is no longer the case. Max will start scouring the entire internet for these ideas in a weekly effort to not only spread but recognize the wealth of knowledge that is out there. This weekly check-in will also give me an excuse to catch up on what’s going on around here more often. What are we calling this idiomatic experiment?

Max’s Back Pocket.

Personal Finance

If you like personal finance stories with real numbers in them as much as I do, the folks over at Fire On The Plains shared their story in January. They started back in 2009 with nearly $130,000 in student debt. By January 2020, they were on their way to being completely debt-free with only $29,000 left on their mortgage. They also put up some serious salaries, blowing out the 250k mark by the end of 2019. Apparently, there is also a 1959 film called Fires on the Plain.

Got Float?

Mrs. Max Out of Pocket and I sold our house down south when we moved to New England a few years back and have been renting ever since. We have zero debt except for the 25-30 day “float” we hold on our credit card interest-free every month. I have paid this balance in full every month for as long as I can remember. We incur absolutely no interest expense on it. I would venture to say I have never paid a dime to the credit card industry in interest. Here is a look at how our “float” looks as of today.

I suppose our financial pick up on this is pretty immaterial since the interest rate on my cash allocation is so low. I guess in the long term, say maybe 1-lifetime unit, it adds up. It also helps us manage our cash flow and extends our emergency fund by about 20k. Note the $20,000 credit limit; a pretty solid emergency fund should we ever need it.

Careful though, you don’t want to “ride the float“. There is a simple test to know if you have fallen into that trap. The folks over at You Need A Budget do a great job explaining this. Are you riding the credit card float?

Still not sure if this applies to you? Here’s the test to determine if you are trapped in the float: If you can’t pay the credit card in full right now AND meet your current obligations, you’ve got debt. You’ve probably been riding the float.

Are you riding the credit card float?

Healthcare

Here at Max Out of Pocket, we took a break from personal finance this week and checked on our options for telehealth. I basically broke everything down to video/audio visits, phone visits, and email/patient portal visits. I even disclosed the billing codes. Next week I am going to take a closer look at the billing and how it might impact our out-of-pocket cost calculation. Just another example of where healthcare intersects personal finance.

Healthcare can be hard to keep up with. The mind behind the Paradigm Shift of Healthcare is certainly making it easier. I like how they try to keep the politics and policy debates out of their content. In episode 37, they touch on responding to negative payment trends. In this episode, they bring on Dr. Tom Davis. He discusses telehealth, healthcare bailouts, and strategy for operating a small physician practice in the current environment.

Dr. Davis warns that although telehealth removes some of the friction from receiving care, it is not a substitute for an actual visit with your doctor and may further fragment the healthcare market. He also compares the 2008 bank bailout to the current situation in the healthcare market and references a “partnership” between health systems and the government. I personally think that’s a stretch, but I suppose I can at least see his thought process.

He warns that the landscape has changed and small clinicians are not only competing against health systems but also the government. Finally, he says payment trends are shifting incentives for performing procedures and thus moving dollars from primary care to specialty services who commonly perform procedures.

Life

Mrs. Max OOP has been teaching her high school kids from home. It’s not easy, but she has been making it work. Apparently, that is nothing compared to homeschooling your own kids. Joe from Retire by 40 says homeschooling is hell! He is using this spring as a trial run since they have plans to take a trip around the world. This trip would theoretically force them into a home-schooling situation.

I suppose it is time for me to finish my coffee and enjoy the rest of my Saturday. The Max out of Pocket crew doesn’t have a ton planned for this weekend, but I am sure we will figure something out. We got some turkey eggs from a colleague at work, so I suppose that is next on the agenda. I have never had turkey eggs!

How was your week?

The post Max’s Back Pocket Vol. IX appeared first on Max Out of Pocket.

But what if there is no need for the doctor to poke around? What if I just need a prescription refilled or five minutes of medical advice? Is there another way?

So today we are here to study up on telehealth. Like many things in healthcare, we have overcomplicated this. There are too many acronyms, technical definitions, and codes. I’m not proud of how complicated this has gotten. But today, we put some of that aside and stick to the basics.

I will even give you the billing codes used most often so you can check in on things.

These alternatives may help keep us out of the doctor’s office while still getting the services we need. Depending on the insurance, it may also help us keep some extra money in our pocket.

Telehealth

The COVID-19 pandemic opened a whole array of options for us to get medical services remotely. Typically, these are usually only available when care from a distance makes sense. In 2020, it makes a lot of sense. So much sense that even Medicare has opened up telehealth. Obviously, if we have a hernia or a broken elbow, we will likely need to be evaluated in person. But in some cases, our doctor or provider doesn’t need to touch us to help us evaluate and manage a problem.

So, what are our options for telehealth?

I am going to attempt to simplify this down to three main visit types. From a “digital” standpoint, we get farther and farther from our doctor as I move down the list.

• Video Visits
• Telephone Visits
• Email/Patient Portal Visits

There are also two more unique scenarios I think are worth calling out.

• Photos and Recorded Videos (sent to our doctor)
• Short Virtual Check-ins

Medicare and several payers have come right out and said they will now cover various forms of telehealth. Unfortunately, that doesn’t mean your insurance covers it. You will want to do your research and make sure you understand what your insurance covers. Then, find out how it will hit your out-of-pocket. Max is only here to guide, I never guarantee.

Video Visits

Video visits are generally two-way communication using an interactive audio and video telecommunications system permitting real-time communication between the provider and patient. That’s a fancy way of describing a secure Skype or Zoom call with your doctor. This is what most people think of when they think of telehealth. It is considered a substitute for an in-person visit. Video visits offer the ability to do an evaluation and management of an issue remotely over video and audio.

Normally, these video services could only be provided to “established” patients. Being an established patient just means we already have a relationship with our medical provider. The government waivers tied to the pandemic have opened these services up to new patients as well.

From a billing standpoint, the regular ‘evaluation and management’ billing codes are used for billing these services. So, on paper, these visits have a similar look (and price) to visits you have with your doctor when you physically set foot in their clinic.

Here are the codes that represent this kind of service.

• 99201 – 99205 for new patients
• 99211 – 99215 for established patients

Generally, as the visit gets more complex and time-consuming, the higher the code used. There are definitely some other codes that might be used for telehealth services, but these are the codes we will most often see.  

Here is where I will try not to overcomplicate things. Your doctor’s office should put a special ‘place of service code’ or ‘modifier’ on the claim to tell your insurance company the services took place through a telehealth visit. That will become important for your insurance company to correctly waive out-of-pocket costs on these visits should they choose to do so. I will give you those tools in another post.

Telephone Visits

Alternatively, non-face-to-face telephone visits are handled a bit differently. These are services provided by your doctor or provider of care over the phone. Normally, they wouldn’t be as thorough of an exam as what you would experience with video evaluation.

These phone calls also generally cannot be billed if they are provided seven days after a formal evaluation and management with a provider. In other words, if you had a 99201 – 99205 or a 99211 – 99215 charged to you in the previous seven days and you speak to your provider over the phone, they should probably not be charging you for the telephone call.

The following billing codes can be used to represent a telephone call with your provider.

• 99441 – five to ten-minute evaluation and management service provided over the phone
• 99442 – eleven to twenty-minute evaluation and management service provided over the phone
• 99443 – twenty-one to thirty-minute evaluation and management service provided over the phone

Any time spent on the call over 30 minutes must be on the house because there isn’t a code for that. Oh, and if they happen to call you into the office as a result of the phone call, they probably can’t charge you for the phone call. This would generally be if the appointment occurred within 24 hours of the call.

Email/Patient Portal Visits

Another option is a non-face-to-face encounter with a medical provider through virtual communication. These are often referred to as “E-Visits”. They would normally be reserved for a patient who has already established care with a medical provider. In this case, there is no video, audio, or telephone conversation. It is all handled through an online patient portal or secure email. It is a patient-initiated, non-face-to-face, digital communication.

These are the billing codes I would expect to see for this scenario. As I mentioned, these are for “established” patients.

• 99421 – five to ten-minute online digital evaluation and management service
• 99422 – eleven to twenty-minute online digital evaluation and management service
• 99423 – twenty-one (or more) minute online digital evaluation and management service

Your provider office should only charge one of these over a 7-day period no matter how many times they communicate with you (it’s cumulative). That said, my understanding is that, unlike the phone visits, our doctor can still charge this even if we saw him or her in the last seven days.

The time on these codes represents the time it takes your doctor or provider of care to review your initial inquiry, review medical records, develop a plan for you, write prescriptions, and respond to you.

Photos and Recorded Videos (sent to our doctor)

Have you ever considered just sending a picture or a video of something to your doctor? They can evaluate the image/video and tell you what is wrong? They have a code for that too. This is sometimes called Virtual Care Communication (store and forward).

• G2010 represents the remote evaluation of a recorded video and/or images submitted by an established patient

There are some rules around this one as well. This code includes the follow-up call with the patient that occurs within 24 hours.

Just like the phone calls, your clinic should not be billing it if you had a formal evaluation and management service with your doctor in the previous 7 days of sending the files. They also cannot bill it if you have a formal evaluation and management service with them within 24 hours after submitting the images. In other words, if they call me in after looking at my boil photo, they shouldn’t charge me for looking at the image.

Virtual Check-In

Virtual check-ins are very much like the short 5-10 minute telephone evaluation and management code above, it just goes beyond the phone call. It represents a brief technology-based communication with your provider that spans 5-10 minutes of medical discussion. Although it is similar to the 99441 telephone service, the code definition technically doesn’t define it as a “telephone only” code. The code represents any technology-based communication. My interpretation is that could include the telephone.

• G2012 represents this type of “virtual check-in” depending on your insurance

Just like the phone calls, your clinic should not be billing it if you had a formal evaluation and management service with your doctor in the previous 7 days. They also cannot bill it if you have a formal evaluation and management service with them within 24 hours of the check-in.

Final Thoughts

So there you have it – telehealth in a nutshell. It is what it is, and I am not proud of how complicated the billing on this has become. But now you have a high-level overview should you ever need it.

The video/audio visits try and substitute an in-person face-to-face visit. Virtual communication (phone/online portal), on the other hand, is a brief discussion to determine if a face-to-face visit is necessary.

In times of pandemic, these are great options to get help with an issue. In theory, it should even work in times of non-pandemic. I personally think this little nudge will push us further into the telehealth model, at least, where that model makes sense.

But how much should these services cost me? How should they be billed? More on that next time, here at Max Out of Pocket.

*Max is not a medical professional and none of this is medical advice. I am not promoting the use of telehealth. Talk over your telehealth options with your provider.

*I am not a “certified coder”. But then again, this stuff isn’t rocket science either once you know where to look. That said, it is not advisable to use Max as formal “regulatory support” for making an argument with your doctor’s billing office. If you are having a billing problem, feel free to contact me by email and I am always happy to try and help or point you in the right direction.

*If you happen to live in a rural community and seek services from a designated ‘rural health center’, as of 4/29/2020 it is still questionable if Medicare will pay the telephone codes 99441-99443. I don’t see any reason a commercial payer wouldn’t pay them, though.

The post Telehealth In A Nutshell: What Are My Options? appeared first on Max Out of Pocket.