The Center for Connected Health Policy reported that Medicare issued a “Change Request” earlier this month, amending the Medicare billing manual. On page 18 of the 21-page amendment, Medicare just happened to mention a 180-degree telehealth coding flip-flop in the policy as to whether the modifier 95 is required.
Part of the Change Request reinforces what therapists discovered months ago – that Place of Service 10 is to be paid at the higher, “non-facility” rate. But the adjustments to underpaid claims from the first quarter of 2024 were finalized several months ago!
So yeah…real speedy on Medicare’s part to issue this old news in July. Our tax dollars at work...
But the rest is alarming news, for those of us who “read the directions” and have billed 2024 telehealth visits without the 95 modifier:
Buried deep on page 18 of the 21-page Change Request 13582, is this directive:
As appropriate, POS 02 or POS 10 may be used and must be paired with the appropriate telehealth modifier (modifier 93 for audio-only and modifier 95 for audio/video)
There’s just one slight problem…in the 2024 Medicare Physician Fee Schedule (the official “rulebook” for 2024), it says,
Here, it says the same thing (page 2).
Telehealth coding flip-flop?! How can they do this?
Well…it’s Medicare. They do these things!
It’s cold comfort, but remember that Medicare is addressing ALL medical specialties, as well as behavioral health. They’re probably not even thinking about mental health services. (are they thinking, at all?)
Throughout 2024, they’ve been paying for telehealth claims submitted with modifier 95, or without. But, if you’re a detail-oriented person (as most billers are), you follow directions. Or if you’ve read my guidance and followed my lead, you’re in the same boat as myself.
I apologize to you for having failed my Divination courses at Hogwarts!
It’s frustrating even for seasoned Medicare billers who have come to expect these kinds of constant adjustments. Seems like as soon as you understand what they want, they go and change it. Changing it going forward is one thing, though. But changing it RETROACTIVELY?
Are we supposed to be psychics? Not bill Medicare for 7 or 8 months each year while they get their act together and figure out once and for all how we’re supposed to code things?
It’s also worrisome. I won’t lie.
Am I going to get clawed back?
That depends on whether Medicare stands firm on this policy or amends it.
I’ve asked for clarification, and I’m sure all professional and billing organizations will as well, or already have done so. Medicare could issue additional information at any time.
If they stand firm that modifier 95 should have been used for all telehealth sessions in 2024, you won’t be clawed back IF you file a reopening form to amend your telehealth billing to include modifier 95.
What’s a reopening and how do I do that?
With commercial claims, to correct a mistake made you re-file the claim with the claim/ICN number in box 22b and a code 7 (for “correction”) in 22a. Not so with Medicare.
To make a change on a Medicare claim, you file a form that’s known as a clerical error reopening, or, more simply, a reopening. Don’t correct your claims the way you would with a private insurer.
Some of the Medicare contractors have interactive reopening forms on their portals. Or, you can submit a paper form if you don’t have a portal account or your contractor doesn’t offer interactive web-based reopening. All contractors have reopening forms available on their websites, and they can be faxed in when completed.
You could even do it via telephone IVR (Integrated Voice Response), although that’s really slow.
A few rules (aren’t there always?)
- Timely filing.
- One year from the date of the Medicare Remittance Advice.
- By filing a reopening, you aren’t disagreeing with the decision Medicare took on the claim. You’re correcting some information on the original claim.
- In the case of adding a modifier, this is an administrative change that will not result in either additional payment or an overpayment determination.
- But it will prevent a future clawback if Medicare decides to reverse payment on telehealth claims without the 95 modifier!
- You can’t file a reopening on a claim that Medicare rejected as unprocessable.
- You can’t add additional lines to a claim via a reopening form. Add the new lines/dates of service on a new claim.
- Don’t make any changes to your original clinical notes. NEVER alter notes after signing/dating!
- The most you should do is file an addendum in your EMR stating that because of updated guidance from CMS, you’re filing the reopening form to add the 95 modifier.
What do I do now?
Start adding modifier 95 to every telehealth session billed to original Medicare, effective immediately.
Hang tight and watch this space for further updates. You’ll have until January 2025 or maybe even later (depending on when you filed your claims) to file reopenings for January 2024 dates of service. Which means there’s no point rushing to file reopenings just yet. Not until Medicare makes a “final” ruling on their telehealth coding flip-flop. If you do any telehealth volume at all, it’s going to be a LOT of paperwork! For no additional income.
You might also insist that your professional organizations file complaints with Medicare. Specifically, ask this:
- What’s CMS’s goal in issuing a directive to code one way, then in mid-year making a retroactive telehealth coding flip-flop that will require a lot of burdensome administrative work?
- How does it benefit Medicare if mental health clinicians have to send thousands of reopening forms in order to keep the money they’ve earned? Medicare contractor employees will have to process all these forms. Aren’t Medicare employees already overwhelmed enough?
There’s (a bit) of good news
Download that Change request. Beginning on page 10, it clarifies place of service codes. And, beginning on page 11, it specifies whether Medicare will pay “facility” (lower) or “non-facility” (higher) rate for each code. And there are more POS codes listed as paying non-facility than previously thought, such as
- 04 Homeless Shelter
- 09 Prison/correctional facility
- 13 Assisted living facility
- 14 Group Home
- 16 Temporary Lodging
- why can’t we use this for telehealth?
- 27 Outreach Site/Street
- 32 Nursing Facility
- don’t confuse with POS 31, “skilled nursing”
- 33 Custodial Care facility
There are others, but my expertise in billing doesn’t extend to those POS codes. For more information please download the change request and/or talk to your Medicare contractor or a certified coder.
However, for telehealth, only POS 02 or 10 is valid, not any of the above POS codes.
And POS 02 (client not at home when receiving the telehealth service) still pays at the lower (facility) rate.
Has Medicare further defined “home” ?
Clinicians struggle with this. Because the client might not be at home when receiving telehealth services. But that doesn’t mean the client is located at a medical facility where the lower “facility” fee is justified.
What if they’re sitting in a park? Or at Starbucks? At the library?
To the best of my knowledge, Medicare hasn’t handed down a clarification.
As always, if you have burning billing issues, questions, or need help, about Medicare or anything else, feel free to schedule a consultation. I’m happy to help!
