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.

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  Analyze the root cause leading to the denial

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  Research Payor and State-specific regulations

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  Holistic approach reviewing the claim in entirety beyond the denial reason

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  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

Denied CPT	Pay or	Corrective Active	Preventive Measure
98970-98972	Medicare	Replace With G codes – CPT G2061 – G2063	Educate coders on Medicare Specific G Coders vs Commercial PayCorrective Actionor CPT code preferences

Missing or incomplete HCPCS
Procedure code/bill type is inconsistent with the place of service

Denied CPT	Corrective Action	Preventive Measure
99201-99215 with POS 02	Replace POS 02 With respective POS code equal to what it would have been in the absence of a PHE meeting the requirements of in person visit. E.g. 11 (office). 22 (Outpatient Hospital) etc.	Stay tuned to CMS Wolvers – CMS has now allowed reporting POS 11 (office). 22 (Outpatient Hospital) etc. for Telemedicine visits: however few Payors still prefer a POS 02 (Telehealth).

The Procedure code is inconsistent with modifier used or a required modifier is missing

Denied CPT	Corrective Action	Preventive Measure
99441-99443, G2012 and G2010, 99421-99423, Found billed with GT/95 Modifier	Remove GT/95 Modifier	Know your modifier rules – GT/95 is not an allowed Modifier an Telephone Visits/Virtual Check-Ins/E-Visits

Invalid Diagnosis Code

Corrective Action	Preventive Measure
Replace appropriate COVID Diagnosis Codes based on Date of service of the Claim 1. Prior to April 1, 2020 – Reported using B97.29 (Other coronavirus as the cause of diseases classified elsewhere) 2. April 1. 2020 or offer – Reported using U07.1 (COVID 19)	Stay tuned to new ICD-10-CM Codes and guidelines from AHA Coding clinic

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

Denied CPT	Payor	Corrective Action	Preventive Measure
99421-99423 G2010, G2012	Medicare	Add/Replace the appropriate CPT code based on Medicare Specifications	Stay tuned to reimbursement Updates: To facilitate reimbursement for the new online digital evaluation and management (CPT codes 99421, 99422, and 99423) or virtual communication service (HCPCS codes G2012 and G2010), RHCs/FQHC’s must submit an claim with HCPCS code G0071 (Virtual non face to face Communication Services- RHC/FQHC 5 min or more) either clone or with other payable services. For claims submitted with HCPCS code G0071 on or after March 1, 2020, and for the duration of the COVID-19 PHE, Payment for HCPCS code G0071 is set at the average of the national non-facility PHS payment rates for these 5 codes.

Denied CPT	Payor	Corrective Action	Preventive Measure
RHC/FQHC Visits (Example – 99201 to 99215)	Medicare	Add the appropriate CPT Code based on Medicare specification	RHC – For telehealth distant site services furnished between January 27, 2020, and June 30, 2020, RHCs must report HCPCS code G2025 on their claims with the CG modifier. Modifier “95” may also be appended but is not required. Beginning July 1, 2020, RHCs should no longer put the CG modifier on claims with HCPCS code G2025. FQHC – The some applies to FQHC qualifying visits. FQHCs must report three HCPCS/CPT codes for distant site telehealth services: The FQHC Prospective Payment System (PPS) specific payment code – (G0466, G0467, G0468, G0469, or G4670) The HCPCS/PCT code that describe the services furnished via telehealth with modifier 95 and G2025 with modifier 95. When furnished services via telehealth that are not FQHC qualifying visits, FQHCs should hold these claims until July 1, 2020, and then bill them with HCPCS code G2025. Modifier 95 may be appended but it is not required (Payor specifics apply) Like RHC’s, Beginning July 1, 2020, FQHCs will only be required to submit G2025. Modifier 95 may be appended but it is not required.
99441-99443	Medicare	Add the appended CPT code based on Medicare specifications	Effective March 1, 2020, allowed Telehealth services include CPT code 99441,99442, and 99443, Which are audio-only telehealth evaluation and management (E/M) services, RHCs and FQHCs can furnish and bill for these services using HCPCS code G2025 with applicable modifier

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

Denied CPT	Corrective Action	Preventive Measure
COVID Claims	Append CS Modifier	CS Modifier is applicable for patients with COVID related conditions. The purpose of using this modifier is to walve the patient responsibility and insurance company will take over 100% payment responsibility (Individual Payor Specifics apply)