Part 4 – Commonly Overlooked Coding Guidelines and Denial Trends
With CMS waivers in place to facilitate coverage of a wide range of Telehealth services, Healthcare sectors are experiencing a new level of complexity to keep pace with evolving codes, guidelines, and payer specifics to enable the first-pass ratio of Telehealth claims.
It is therefore important to stay prepped to handle the expected surge in coding denials associated with these virtual visits, to begin with, alongside strategizing ways and means to reduce them.
Coding denial management experts rely on 4 key ground rules when resolving coding edits and denials that very much apply to Telehealth-related denials too.
1) Analyze the root cause leading to the denial
2) Research Payor and State-specific regulations
3) Holistic approach reviewing the claim in entirety beyond the denial reason
4) Track top denial trends and strategize preventive measures to avoid future denials.
Telehealth and Top denial trends
The table below outlines the Root cause behind the frequently encountered coding Denials from Telehealth Visits along with Corrective and Preventive measures
Missing/incomplete/invalid HCPCS
Missing or incomplete HCPCS
Procedure code/bill type is inconsistent with the place of service
The Procedure code is inconsistent with modifier used or a required modifier is missing
Invalid Diagnosis Code
Federally Qualified Healthcare Center (FQHC) and Rural Health Center (RHC) Prospective Payment System (PPS) Type of Bill (TOB) 77x is submitted and at least one of the specific payment code(s) is not present
G0071 (Complete Code Description) - Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between a rural health clinic (RHC) or federally qualified health center (FQHC) practitioner and RHC or FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC practitioner, occurring in lieu of an office visit; RHC or FQHC only
G2025 (Complete Code Description)- Distant site telehealth services Rural Health Clinics or Federally Qualified Health Centers (RHC/FQHC)
CG Modifier - Policy criteria applied
Co-Pay/Co-Insurance deductible
RHCs and FQHCs must also report modifier CS. CMS has modified the descriptor of the CS modifier to account for this additional use as follows:
CS - Cost-sharing waived for specified COVID-19 testing-related services that result in, and order for or administration of a COVID-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in Rural Health Clinics and Federally Qualified Health Centers during the COVID-19 public health emergency.
For preventive services that are furnished via telehealth and have cost-sharing waived, RHCs must report G2025 on their claims with the CG and CS modifier, and FQHCs must report G2025 with the CS modifier on or after July 1, 2020.
About the Authors
Kavitha Velumani, CPC, COC, Assistant Director of Coding Operations at Access Healthcare, carries over 15 years of domain experience spread across diverse specialties. In her role, Kavitha oversees Prospective coding services for Physician groups and Hospitals in addition to Coding denial management offerings.
Rukmani Kumar P C, CPC, comes with 9+ years of Multi-Specialty coding expertise, currently playing the role of a Project manager assisting the Transition of new coding projects at Access Healthcare.
Santhosh Kumar N, CPC, CCS, is a Coding subject matter expert with 5+ years of multi-specialty coding experience. Santhosh plays the role of coding denial specialist at Access Healthcare, assisting coders with evolving payer specifics and denial resolution strategies.
That brings us to the end of this 4-part online blog series. We hope you enjoyed reading. See you soon with more interesting topics and articles. Until then, Stay healthy and Happy Learning!