Wiki Telehealth Billing after PHE and changes to place of service causing lower reimbursement

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lisaray

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I am very confused why all of a sudden we are seeing denials using place of service 11 with modifier 95 and now they want us to use POS 10 for telehealth in patient's home and POS 02 if they are not home. It seems to vary by payer and I know some are following Medicare guidelines but we are being reimbursed less using this place of service. It takes just as much time and effort to conduct services. Why do they pay less? I just received a denial on a claim for a Humana Medicare advantage claim. Anyone have any input or knowledge would be much appreciated. I did see there is a bulletin on Humana's website via availity noting a change. Here is how claim processed
Procedure DOS Code Type Code TranslationHC: 99213:95 01/03/2024 HE M77 Missing/incomplete/invalid/inappropriate place of service.
We used POS 11 Anyone else seeing this issue? Thanks
 
lisaray said:
I am very confused why all of a sudden we are seeing denials using place of service 11 with modifier 95 and now they want us to use POS 10 for telehealth in patient's home and POS 02 if they are not home. It seems to vary by payer and I know some are following Medicare guidelines but we are being reimbursed less using this place of service. It takes just as much time and effort to conduct services. Why do they pay less? I just received a denial on a claim for a Humana Medicare advantage claim. Anyone have any input or knowledge would be much appreciated. I did see there is a bulletin on Humana's website via availity noting a change. Here is how claim processed
Procedure DOS Code Type Code TranslationHC: 99213:95 01/03/2024 HE M77 Missing/incomplete/invalid/inappropriate place of service.
We used POS 11 Anyone else seeing this issue? Thanks
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We recv'd the same exact denial (M77) this past Monday (01/08/24). We billed exactly as you did (99213-95 POS 11 - even same DOS (Ha Ha)). Insurance is Humana Medicare. It doesn't look like the denial has been worked yet.
As a side note, BCBS put out a bulletin last week stating they want to see the same change (POS 10 when pt is at home/02 when they're not). We've been billing POS 02 for BCBS telehealth but our office agreed just this week to try POS 10. Reimbursement is still up in the air; I'm not even sure we've billed one yet.
I know this isn't much help but to say we're seeing the same thing. We're a group Pain Management practice in Texas.
 
I went out to the Medicare MLN sheets to see if all Medicare will be changing and it couldn’t be more muddy.



These 2 paragraphs are contradicting each other .

1705079961470.png

The first paragraph states for 2024 to use POS you’d bill for in person (11). The second paragraph states use POS 02 or 10.
(I'm so confused here).
Are we to use the 95 modifier and POS 02-Telehealth for all Telehealth claims now? Including Humana/Humana Medicare?
 

Always depends on the payer being billed and their current telehealth policy.

Possibility is reimbursement varies and may be less for 10 or 02 because the patient is not physically in the provider's office therefore there is no physical "office cost". I don't know if this is why for sure, just a thought. The physician can be in their own home or at the hospital or somewhere else and therefore, there is no cost to them associated with having "doors open" and "lights on" in a physical office building. (Might be this not sure.)
You would have to look up the payer's fee schedule for CPT and POS combos as well as could be something with a provider or group's contract.
 
sherrygalla said:
I went out to the Medicare MLN sheets to see if all Medicare will be changing and it couldn’t be more muddy.



These 2 paragraphs are contradicting each other .

View attachment 6745

The first paragraph states for 2024 to use POS you’d bill for in person (11). The second paragraph states use POS 02 or 10.
(I'm so confused here).
Are we to use the 95 modifier and POS 02-Telehealth for all Telehealth claims now? Including Humana/Humana Medicare?
Click to expand...
Thank you Sherry for responding. I am new to this forum thing and I agree that it is clear as mud. I checked PalmettoCms website too and I agree.
I will update this thread and anyone interested when I see how this claim processes from Humana Medicare. I sent a corrected claim referencing the original claim number and using POS 10 instead of 11.
 
sherrygalla said:
I went out to the Medicare MLN sheets to see if all Medicare will be changing and it couldn’t be more muddy.



These 2 paragraphs are contradicting each other .

View attachment 6745

The first paragraph states for 2024 to use POS you’d bill for in person (11). The second paragraph states use POS 02 or 10.
(I'm so confused here).
Are we to use the 95 modifier and POS 02-Telehealth for all Telehealth claims now? Including Humana/Humana Medicare?
Click to expand...
I agree with you, these two statements above and in the link below make no sense and conflict. I read it like twelve times just to make sure LoL. There was a point where CMS said they did not want POS 10 as they had found no applicable use for it and instructed MACs as such. I think it was in 2022 when those POS came out. Maybe now they changed it. Can also check the CMS manual for telehealth rules. I assume we are talking about office E/M? It can depend on the type of service too.
On your modifier 95 question, it is stating modifier 95 for the scenario in the sentence only (clinician in hospital patient in home and/or outpatient therapy).
As far as Humana or Humana MCR, you have to check and follow what they state. I assume it would follow CMS but you never know for sure. You wouldn't assume the CMS fact sheet or policy applies to a payer unless you check with the specific payer. While a MCR replacement would, almost all of the time, follow, or be required to follow MCR, they can sometimes divert to their own weird policy.

If you read this HHS guidance, it is 02 & 10.

Regarding payments:
There were changes for telehealth payments (2024) in the final rule too. You would have to consider what year you are looking at on your claim in question and the fee schedule.
 
This 2024 telehealth language is not direct enough for me. We are an Independent Primary Care Practice. I billed Blue Medicare NC and Palmetto GBA CPT 99213 using POS 10. Neither payer paid at parity.
 
MariaG said:
This 2024 telehealth language is not direct enough for me. We are an Independent Primary Care Practice. I billed Blue Medicare NC and Palmetto GBA CPT 99213 using POS 10. Neither payer paid at parity.
Click to expand...
EDIT: Effective Jan 1, 2024 - Medicare Part B pays the facility rate when the patient is not at home (POS 10) and the non-facility rate when the patient is NOT at home (POS 02).

Apologies, as two people have noted I got my POS completely backwards here.
 
Last edited:
jkyles said:
Effective Jan 1, 2024 - Medicare Part B pays the facility rate when the patient is not at home (POS 10) and the non-facility rate when the patient is at home (POS 02).
Click to expand...
I was just noticing that you switched the POS/descriptions. 02 is for patient not at home. 10 is for patient at home (or "a location other than a hospital or other facility where the patient receives care in a private residence.") https://www.ngsmedicare.com/web/ngs...Id=10638446&lob=96664&state=97133&rgion=93623
 
jkyles said:
Yes, I've only looked at that portion of the rule a thousand times. I don't know what I was thinking then. o_O
Click to expand...
Well, maybe if they stopped changing the guidelines, it would be easier. I KNEW that you KNEW, but wanted to make sure anyone else reading also knew. :ROFLMAO:
 
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