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Showing posts with label Fee Schedule. Show all posts
Showing posts with label Fee Schedule. Show all posts

Telehealth Updates 2023

The CMS released new updates in January 2023 for the medicare fee schedule summary for telehealth services. 

The updates are effective from January 1, 2023 and the implemented date is January 3, 2023. 

The major changes are Medicare Physician Fee Schedule and mentioned following four category and every providers, coders and billing staff knows this guidelines and changes.

  • Telehealth originating site facility fee payment amount
  • Expansion of coverage for colorectal cancer screening
  • Coverage of Audiology services
  • Other covered services

The Medicare will continue to pay the telehealth service payment at same rate in person outpatient fee rate through out end of the 2023, And there is no changes and or decrease the fee rate. 

And also, the Medicare will continuously paying the audio visit service CPT code 99441, 99442 & 99443 at the same rate of outpatient established office rate for the length of service/time spends with the patient.

For Medicare patients, the provider would continue to bill the telehealth claims with the place of services indicate that the service bill under In-Person visit. And the claims must be billed with modifier 95 to indicate the service is performed in telehealth.

For Medicare adding new HCPCS codes to the list of telehealth services on a category 1, and the HCPCS codes are G0316, G0317, G0318, G3002, and G3003.

We are keeping many services that are temporarily available as telehealth services for the duration of  the COVID-19 Public Health Emergency (PHE) on a Category 3 basis through CY 2023 and including the following CPT codes.

The CPT codes are 90875, 90901, 92012, 92014, 92550, 92552, 92553, 92555-92557, 92563, 92567, 92568, 92570, 92587, 92588, 92601, 92625-92627, 94005, 95970, 95983, 95984, 96105, 96110, 96112, 96113, 96127, 96170, 96171, 97129, 97130, 97150-97158, 97530, 97537, 97542, 97763, 98960-98962, 99473, 0362T, and 0373T. 

These codes are available up to through December 31, 2023 in Medicare telehealth list.

The Category 3 CPT codes in telehealth services will be covered through 2023 and the Non-facility payment rates for telehealth services will remain the same through 2023 (physician offices are defined by Medicare as “Non-Facility” setting.

So this means telehealth payments will remain the same as in-person through 2023 and the direct supervision may continue to be provided virtually through 2023.

The CMS decided to continue paying for all of the codes on the telehealth list that were scheduled to stop 151 days after the PHE through the end of 2023.

Telehealth Originating site facility fee rate Update

The payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80% of the lesser of the actual charge, or $28.64 for CY 2023 services.

Other than office visit codes, the E/M visits includes following,

  • Hospital inpatient, 
  • Hospital observation, 
  • Emergency department, 
  • Nursing facility, 
  • Home services, 
  • Residence services, and 
  • Cognitive impairment assessment visits.
For 2023, Medicare adopting the revised CPT codes for Other E/M visits (except for prolonged services)
  • G0316 for reporting prolonged hospital inpatient or observation services
  • G0317 for prolonged nursing facility services
  • G0318 for prolonged home or residence services
  • G2212, for  prolonged office/outpatient services
  • G3002 - Chronic Pain Management
  • G3003 - Chronic Pain Management 

Place of Service Updates

The place of services code is provided to pay the claims correctly at the same time the health care providers need for the specificity than Medicare for the services rendered. And the Medicare does not always need this greater the specificity to pay the claims.

The following two codes are created to meet the industry standards,

POS 02: Telehealth Provided Other than in Patient’s Home Descriptor

  • The location where health services and health related services are provided or received, through telecommunication technology. 
  • Patient is not located in their home when receiving health services or health related services through telecommunication technology. 

POS 10: Telehealth Provided in Patient’s Home Descriptor

  • The location where health services and health related services are provided or received through telecommunication technology. 
  • Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology

But the Medicare does not identified a need for new place of service code (POS 10). The MACs will instruct their providers to continue to use the Medicare billing instructions for Telehealth claims in specified under section Pub. 100-04.

Golden Rule - Pulse Oximetry with Evaluation & Management

CPT Code Description: -

94760 - Noninvasive ear or pulse oximetry for oxygen saturation; single determination

94761 - Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (e.g., during exercise) 

The provider and or other qualified healthcare professional takes the oxygen saturation using the a sensor on the ear or finger from the patients.

To perform this service, the doctor places a sensor, such as one in the form of a clip, on the patient’s earlobe or fingertip.

The sensor uses a light shining through the body part to measure the oxygen saturation, detecting the differences in the ways blood cells with and without oxygen reflect light.
The Oxygen saturation, is also called as O2 sat, and the percentage of hemoglobin carrying oxygen molecules.

Guidelines: -

The CPT Codes ranges from 94010 to 94799 include laboratory procedure(s) and interpretation of test results.

If a separate identifiable evaluation and management service is performed on the same day, the appropriate E/M service code can be billed separately. Like,
  • New or Established Patient Office or Other Outpatient Services (99202 to 99215),
  • Office or Other Outpatient Consultations (99242 to 99245),
  • Emergency Department Services (99281 to 99285),
  • Nursing Facility Services (99304 to 99316),
  • Home or Residence Services (99341 to 99350),
The mentioned above listed CPT codes may be reported with modifier 25 based on the NCCI edits guidelines in addition to the 94010-94799.

General Information: -

The pulse oximetry codes are not reportable with any other service performed on the same day.

There is no NCCI edits for this CPT codes, but as per the CMS guidelines, the Medicare Physician as categorized into the "T" status code, which means they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider.

Additional Information: -

Pulmonary function tests (94011-94013) are reported for measurements in infants and young children through 2 years of age.

Pulmonary function testing measurements are reported as actual values and as a percent of predicted values by age, gender, height, and race.

Fee Schedule Updates - 2022

The fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. The CMS develops a fee schedules for following services,
  • Physicians Services,
  • Ambulance services,
  • Clinical laboratory services, 
  • Durable Medical Equipment Services,
  • Prosthetics Services,
  • Orthotics Services,
  • Supplies Services.

The Overall, neurosurgery will receive a 3.2% payment cut in 2022. The cut stems from a lower conversion factor from $34.89 in 2021 to $33.58 in 2022. 

In the final rule CMS lowered the conversion factor (CF) from $34.89 in calendar year of 2021 to $33.59 for CY 2022, a decrease of $1.30 (-3.7%). 

This is due in part to the expiration of the 3.75% payment increase provided for in Year of 2021 by the Consolidated Appropriations Act of 2021

With the 2% Medicare sequester set to resume next year and additional Medicare payment cuts of up to 4% possible under pay-as-you-go rules to pay for the American Rescue Plan, providers could be facing up to 9% in payment cuts next year unless Congress intervenes.

Absent congressional actions, a 9.75% cut was scheduled effective January 1, 2022.

*Congress reduced 3% of the scheduled 3.75% cut to the Medicare Physician CF.

Evaluation and management (E/M) visits

The CMS clarifies and refines policies related to split (or shared) evaluation and management (E/M) visits, critical care services, and services furnished by teaching physicians involving residents. 

The Split (or shared) E/M visits are defined as visits provided in a facility setting by a physician and a non-physician provider in the same group. 

The practitioner who provides the substantive portion of the visit would bill for the visit. For 2022, the substantive portion is determined based on the below information,

  • Medical History, 
  • Physical Exam, 
  • Medical Decision Making OR 
  • More than half of the total time.

Additionally, critical care services will not be bundled in a global surgical period if unrelated to the surgical procedure. 

The rule clarifies that when a resident participates in providing a service, only the time the teaching physician was present can be included in determining the E/M visit level. Under the primary care exception, only medical decision-making would be used to select the visit level.

Modifier GC to be used when the teaching physician rendered the service to indicate as " The services performed in part by a resident under the direction of a teaching physician.

The CMS permits certain services added to the Medicare telehealth list to remain on the list until December 31, 2023, to collect data to determine whether services should be permanently added to the telehealth list following the COVID-19 public health emergency (PHE).

Payment Modifier Details 

Payment modifiers are accounted for in the creation of the file consistent with current payment policy as implemented in claims processing. 

  • For example, services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for that service; therefore, the utilization file is modified to only account for 16 percent of any service that contains the assistant at surgery modifier.

Telehealth eye exam

The CMS continues to evaluate the inclusion of telehealth services that were temporarily added during the COVID-19 public health emergency, the agency finalized certain services added to the Medicare telehealth services list through Dec. 31, 2023. 

The AOA raised concerns with the inclusion of the eye exam codes on the telehealth covered services list, yet CMS did not address these codes. However, it did note that all services on the current telehealth covered services list would remain until 2023.

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