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Well, school is back in session here at Max Out of Pocket. Last week I went through some of the options we have for telehealth. Those include video visits, telephone visits, e-visits, and a few other options we have in our back pocket. We even went through most of the billing codes that represent some of the ‘digital services’ we can get from our doctor. But how does my insurance know the services are telehealth? How do we know if this stuff is getting billed correctly?
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
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.
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.
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.
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!