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Telemedicine and Prior Authorization for Outpatient Hospital Services

Tuesday, June 2, 2020   (0 Comments)
Posted by: Joy Newby, LPN, CPC, Newby Consulting Inc
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Update on Telemedicine Service Codes

The following Telemedicine Frequently Asked Questions were published on 5/27/2020.

Question: What telephone-only service codes were finalized as telehealth services for the duration of the PHE?

Answer: For purposes of the PHE for the COVID-19 pandemic, Medicare has added several codes that describe telephone-only services to the list of Medicare telehealth services. These include CPT codes 99441–99443, which describe audio-only telephone evaluation and management (E/M) phone visits with practitioners who can independently bill for E/M services. While these codes are ordinarily limited to established patients, during the public health emergency (PHE), Medicare will make payment for them for both new and established patients. These services are noted on the list of telehealth services at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/TelehealthCodes.

Please report the POS that would have used had the service occurred in person for these telephone-only service codes and all other telehealth services during the PHE.

In addition, while not currently on the Medicare telehealth services list, during the PHE for COVID-19, CMS pays CPT codes 98966–98968, which describe audio-only telephone assessment and management visits for practitioners who cannot independently bill for E/M phone visits, for example certain therapists, social workers, and clinical psychologists.

Question: If the video connection is disconnected during an audio-video Medicare telehealth visit due to technological issues, can the visit still be billed as Medicare telehealth?

Answer: Practitioners should report the code that best describes the service. If the service was furnished primarily through an audio-only connection, practitioners should consider whether the telephone evaluation and management or assessment and management codes best describe the service, or whether the service is best described by one of the behavioral health and education codes for which we have waived the video requirement during the PHE for the COVID-19 pandemic. If the service was furnished primarily using audio-video technology, then the practitioner should bill the appropriate code from the Medicare telehealth list that describes the service. Note that CPT codes 99441–99443, which describe audio-only telephone E/M phone visits with practitioners who can independently bill for E/M services, have been added to the Medicare telehealth list for the purposes of the PHE for the COVID-19 pandemic, and payment rates for these codes are set to be the same as the analogous in-person E/M visits.

Question: How should telehealth services be documented in the medical record (e.g., face-to-face time, preparation time)?

Answer: CMS expects the same level of documentation that would ordinarily be provided if the services furnished via telehealth were conducted in person.

Question: How should practitioners bill for audio-only services that last longer than 30 minutes?

Answer: During the PHE for the COVID-19 pandemic, Medicare has added to the list of telehealth services CPT codes 99441–99443, which describe audio-only phone visits with practitioners who can independently bill for E/M services, and CPT codes 98966–98968, which describe audio-only phone visits with practitioners who cannot independently bill for E/M services (for example certain therapists, social workers, and clinical psychologists).

CPT codes 99443 and 98968 describe 21–30 minutes of medical discussion, respectively for each practitioner type; but there are no CPT codes available to describe medical discussions lasting longer than 30 minutes.

Question: Where can I find information about coding for the 2019 novel coronavirus disease (COVID-19)?

Answer: You can find information about coding for the 2019 novel coronavirus disease (COVID-19) from the four cooperating parties for the ICD-10-CM. The four cooperating parties are the American Hospital Association, American Health Information Management Association, Centers for Medicare & Medicaid Services, and the Centers for Disease Control and Prevention/National Center for Health Statistics.

Centers for Disease Control and Prevention/National Center for Health Statistics:

Centers for Medicare & Medicaid Services:

A frequently asked questions (FAQ) document, jointly developed and approved by two (2) of the four (4) cooperating parties for ICD-10-CM, the American Hospital Association’ Central Office on ICD-10-CM/PCS (the official U.S. Clearinghouse on medical coding) and the American Health Information Management Association is available at:

Prior Authorization for Blepharoplasty and Botox Procedures for Place of Service Outpatient Hospital

The following information only applies to blepharoplasty and botulinum toxin injection procedures performed in hospital outpatient departments (OPD). It does NOT apply to procedures performed in the office or ambulatory surgery centers (ASC).

The Centers for Medicare & Medicaid Services (CMS) has issued some instructions related to the new prior authorization (PA) requirements for Hospital Outpatient Department (OPD) Services Benefits effective July 1, 2020. At this time, due to a recent CMS teleconference, we do not anticipate a delay in PA implementation.

The Medicare Administrative Contractors (MACs) will begin accepting Prior Authorization Requests (PARs) for these services on June 17, 2020, for services provided beginning on or after July 1, 2020. Submissions sent through esMD ( Electronic Submission of Medical Documentation) will begin on July 6, 2020. For PAR submissions sent prior to July 6, 2020, providers should use their MAC’s portal, fax, or mail. PA determinations are valid for 120 days from the date the decision was made.

PA is a process through which a request for provisional affirmation of coverage is submitted for review before the service is rendered to a patient and before a claim is submitted for payment. Prior authorization helps to make sure that applicable coverage, payment, and coding rules are met before services are rendered.

For ophthalmologists performing the following procedures in a hospital outpatient department, prior authorization must be obtained for the surgical procedure.

 

Code

Blepharoplasty, Eyelid Surgery, Brow Lift, and related services

15820

Removal of excessive skin of lower eyelid

15821

Removal of excessive skin of lower eyelid and fat around eye

15822

Removal of excessive skin of upper eyelid

15823

Removal of excessive skin and fat of upper eyelid

67900

Repair of brow paralysis

67901

Repair of upper eyelid muscle to correct drooping or paralysis

67902

Repair of upper eyelid muscle to correct drooping or paralysis

67903

Shortening or advancement of upper eyelid muscle to correct drooping or paralysis

67904

Repair of tendon of upper eyelid

67906

Suspension of upper eyelid muscle to correct drooping or paralysis

67908

Removal of tissue, muscle, and membrane to correct eyelid drooping or paralysis

67911

Correction of widely-opened upper eyelid

 

Code

Botulinum Toxin Injection

64612

Injection of chemical for destruction of nerve muscles on one side of face

64615

Injection of chemical for destruction of facial and neck nerve muscles on both sides of face

J0585

Injection, onabotulinumtoxina, 1 unit

J0586

Injection, abobotulinumtoxina

J0587

Injection, rimabotulinumtoxinb, 100 units

J0588

Injection, incobotulinumtoxin a

 

According to CMS, the hospital is responsible for the actual obtaining of the prior authorization; however, the medical necessity information will typically be documented in the physician’s medical record. This means hospitals and physicians will need to work together to ensure prior authorization is obtained prior to the procedure being performed. Procedures without the required prior authorization will be denied. The denial will be applied to the hospitals’ claims as well as all other related claims including physician claims.

If an applicable claim is submitted without a PA decision and is flagged as having an ABN, it will be stopped for additional documentation to be requested and a review of the ABN will be performed (to determine the validity of the ABN) following standard claim review guidelines and timelines. The provider should submit the claim with the -GA modifier appended to applicable CPT/HCPCS codes. The Contractor will determine the validity of the ABN in accordance with standard ABN policies.

At the time this article was written, Medicare Administrative Contractor (MAC) have been posting information regarding PA on their Part A website. We have not found information on MACs’ Part B website. Expect to hear from your hospitals for the process they will want to follow for prior authorization requests (PAR). It is possible the hospital will ask the physician to complete the PA request or a portion of the PA request on its behalf.

CMS has instructed its Medicare Administrative Contractors (MAC) to begin accepting requests for prior authorization (PA) effective June 17, 2020. The standard review timeframe is ten (10) business days from the date the prior authorization request is received, excluding federal holidays.

An expedited review (decision in two business days) can be requested if the documentation supports the fact that the delay in obtaining the PA could seriously jeopardize the patient’s life, health, or ability to regain maximum function. The requester will be notified regarding the acceptance of the PAR for expedited review or if it will convert the request to the standard PA review process.

The request for an expedited review will not be granted because the physician has already scheduled the procedure and the PA was not requested in a timely manner.

The following three (3) decisions are applicable to PARs:

  • provisional affirmation decision
  • partial affirmation decision
  • a non-affirmation decision

A provisional affirmation decision is a preliminary finding that a future claim submitted to Medicare for the item or service likely meets Medicare’s coverage, coding, and payment requirements.

A provisional partial affirmation decision means that one or more service(s) on the request which includes multiple CPT/HCPCS codes receives a provisional affirmation decision and one or more service(s) received a non-affirmation decision.

A non-affirmation decision is a preliminary finding that if a future claim is submitted for the item or service, it does not meet Medicare’s coverage, coding, and payment requirements.

The prior authorization decision will be based on the (MAC) Local Coverage Determination (LCD). Physicians should review LCDs for medical necessity and documentation requirements. At the time this article was written, there were no changes in the Blepharoplasty and Botulinum Toxin LCDs related to the PA requirements.

  • General Documentation Requirements for Blepharoplasty, Eyelid Surgery, Brow Lift, and related Services:
    • Documented excessive upper/ lower lid skin
    • Supporting pre-op photos
    • Signed clinical notes support a decrease in peripheral vision and/or upper field vision
    • Signed physician’s or non-physician practitioner recommendations
    • Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.)
    • Visual field studies/exams (when applicable)
  • General Documentation Requirements for Botulinum Toxin Injections:
    • Support for the medical necessity of the botulinum toxin (type A or type B) injection
    • A covered diagnosis
    • Dosage and frequency of planned injections
    • Support of the clinical effectiveness of the injections (for continuous treatment)
    • Specific site(s) injected

Basic PA Information

The following information includes a detailed explanation of the PA requirement.

The prior authorization request (PAR) must be submitted before the service is provided to the patient and before the claim is submitted for processing. The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding, and payment rules.

At the time this article was written, CMS provided some guidance regarding the information that must be included in the PAR. MACs may request additional, optional elements for submission of the PAR.

Initial Submission Documentation:

Beneficiary Information (as written on their Medicare card)

  • Beneficiary Name
  • Beneficiary Medicare Number (also known as the MBI)
  • Beneficiary Date of Birth

Hospital OPD Information

  • Name of facility
  • PTAN/CCN
  • Facility Address
  • Facility National Provider Identifier (NPI)

Physician/Practitioner Information

  • Physician/Practitioner’s Name
  • Physician/Practitioner’s National Provider Identifier (NPI)
  • Physician/Practitioner PTAN
  • Physician/Practitioner’s Address

Requestor Information

  • Requestor Name
  • Requestor Phone Number
  • Requestor Email Address

Other Information

  • Anticipated Date of service
  • CPT/HCPCS Code(s)
  • Diagnosis Code(s) (providers who submit using esMD must include a diagnosis code(s))
  • Type of hospital Bill
  • Units of Service (providers who submit using esMD must include units of service)
  • Indicate if the request is an initial or subsequent review
  • Indicate if the request is expedited and the reason why

Resubmission (s) documentation

  •  In addition to the required PAR documentation in the Initial Submission section, the resubmission of the PAR should contain an exact match of the patient's first name, last name, date of birth to the previous submission, and the unique tracking number (UTN) associated with the previous submission.

The following three (3) responses are applicable to PARs:

  • provisional affirmation decision
  • partial affirmation decision
  • a non-affirmation decision

The MAC will send the requester of the prior authorization request (i.e., the hospital submitting the claim for payment) a written decision (i.e., provisional affirmation, provisional partial affirmation, or non-affirmation), and if applicable, provide the detailed reasons for the non-affirmation decision. The MAC will also share such information with patients.

If a non-affirmation is received, providers should review the information included in the decision and consider if there is additional documentation that could address the non-affirmation decision upon resubmission of the prior authorization request. Providers may also request additional information or clarification from their MAC.

A resubmitted request is a subsequent review request submitted after the initial review request was submitted, reviewed, and a non-affirmation decision was made. A request that is resubmitted with no additional documentation or information will likely receive a non-affirmation decision. Provided the claim has not been submitted for payment, the provider may resubmit the prior authorization request to their respective MAC an unlimited number of times.

The provider should review the detailed decision letter that was provided. A provider may resubmit a PAR an unlimited number of times upon receipt of a non-affirmative decision. The prior authorization unique tracking number (UTN) will be assigned to each PA resubmission request.

Non-affirmation decisions are not considered initial determinations and cannot be appealed; however, if a claim is submitted with a non-affirmation decision, and the service is subsequently denied, it will be considered an initial determination and the denial is appealable.

MACs will include a prior authorization unique tracking number (UTN) on decision notices. The UTN must be submitted on the hospital’s claim in order to receive payment. Claims billed without first submitting a prior authorization request and receiving a provisional affirmation decision will be denied payment.

At the time this article was written, physicians are not required to include the UTN on their claims.

PAR decisions and UTNs for these services are valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on January 1, 2021, the PAR will be valid for dates of service through April 30, 2021. Otherwise, the provider will need to submit a new PAR.

Hospitals are reminded that claims for payment must include the UTN that was received in response to their prior authorization request, to indicate that a prior authorization decision was made, and whether it has a provisional affirmation decision or non-affirmation decision. If a UTN is not included on the hospital’s claim for payment or is related to a non-affirmation decision, the MAC will deny the claim for failing to meet the prior authorization requirements as a condition of payment.

Generally, the claims that have a provisional affirmation decision will not be subject to additional review; however, CMS contractors, including Unified Program Integrity Contractors MACs, may conduct targeted pre- and post-payment reviews if the provider shows evidence of potential fraud or gaming. In addition, the Comprehensive Error Rate Testing contractor must review a random sample of claims for post-payment review for purposes of estimating the Medicare improper payment rate.