Coding & Billing Updates

Information provided by: Carol Hoppe, CPC, CCS-P, CPC-I
Healthcare Consultant | MedLucid Solutions, LLC

January 10, 2022

Updated Telehealth Grid For 2022 (PDF file) 

Note from Carol Hoppe: This chart shows the payers who are most likely to adopt the new Place of Service codes for telehealth in 2022. CMS guidelines noted a 1/1/2022 effective date and a 4/4/2022 implementation date, but on the WPS webinar from last week, it was indicated that during the PHE we should continue to list the POS where the services would normally have taken place if the patient was seen in person. Therefore, I have included POS 11 on the attached cheat sheet since this was an office based project when I put it together in the beginning of the PHE. For those of you who see patients in other locations via telehealth, you would use the POS that corresponds with those locations.

October 26, 2021

October 2021 Updates From Anthem (PDF file)
Downloads (all PDF files)
Smoking Cessation Provider Incentive Program
Health Needs Screening Provider Tutorial
Health Needs Screening Provider Incentive Program Description
Physical Health Provider Experience Managers

July 2, 2021

The future of telehealth status post the COVID public health emergency:

Everyone is interested in what the future of telehealth will look like after the COVID-19 public health emergency (PHE), and it is difficult to stay abreast of all the changes. Some payers, such as Aetna, have resumed pre-COVID rates for telephone-only codes 99441-99443. Read a quick snapshot of what other payers are doing (PDF file).

View the most up to date Coding for Telehealth Quick Reference Guide here (PDF file).

Medicare Annual Wellness Visit Common CERT Denials:
WPS Medicare notes recent claim reviews performed by the Comprehensive Error Rate Testing (CERT) contractor with several error findings for Annual Wellness Visits (AWV). The documentation submitted was missing certain requirements. Click here to read more (PDF file).

January 1, 2021

Please review an updated summary of the changes in payer policies related to COVID and non-COVID telehealth services. Please note there is additional information for each payer if you click on the links to the payer websites.

UHC provided a Summary of COVID-19 Dates by Program, which can be found here:

It's hard to summarize all of this on a one page document, so you may need to reference this document for additional information depending on your specialty or patient population.

I've also attached a two page summary of the 2021 E/M Changes that go into effect on 1/1/2021. Page 1 is the information for coding based on TIME and Page 2 is just a bigger version of the new MDM table for those for whom the print on the AMA version was too small. You can print and laminate these two pages to have available while you learn the new guidelines. I also recommend reading through the 16-page document from the AMA where the new definitions are explained before you get started coding your E/M services next week. I truly wish you all the best as you make the transition to this first phase of E/M Changes.

WPS has published the 2021 Medicare Physician Fee Schedules (MPFS) and Anesthesia Conversion Factors (ACF) on their website. You can access the 2021 Medicare Physician Fee Schedules (MPFS) here. You can access the Anesthesia Conversion Factors from the 2021 Specialty Pricing web page. 

Note - Anthem is not covering code G2211
Evaluation and management changes 2021 | Jan 1, 2021 • Administrative

Anthem Blue Cross and Blue Shield (Anthem) recognizes all coding changes from both the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) effective the date provided by the coding source. This includes the Evaluation and Management (E/M) changes effective January 1, 2021.

The following updates pertaining to Evaluation and Management services have been identified:

  • CPT code 99201 (new patient E/M) will be a deleted code.
  • CPT codes 99202 through 99215 (new/established E/M) definitions have changed. Selection of these E/M codes can now be based on either Medical Decision Making or Time.
  • CPT code 99417 (prolonged services) and HCPCS Code G2212 (prolonged services) will be recognized as billable codes. These codes will be payable based on our existing Prolonged Services policy, which will be updated to reflect the new code along with the modifications to existing prolonged service codes CPT codes 99354 and 99355.
  • HCPCS Code G2211 (complexity inherent to evaluation and management associated with primary medical care) will not be separately reimbursed for this service. We will be updating our Bundled Services and Supplies policy to reflect this position.

Additionally, we are in the process of updating reimbursement policies impacted by the E/M service changes such as the Documentation and Reporting Guidelines for Evaluation and Management Services. 

New law delays changes to the Medicare Physician Fee Schedule
Among the many provisions impacting health care providers in the new COVID-19 relief package signed on Monday 12/28, is a moratorium on some of the changes to the Medicare Physician Fee Schedule. Specifically, the new evaluation and management “add-on” code (G2211) which was to begin in 2021 to account for added complexity in outpatient visits, has been delayed three years. This change means that the full extent of expected Medicare cuts – including those for home visits – is also delayed, since the G-code would have triggered some substantial cuts to ensure budget neutrality. In addition, all providers will receive an increase of 3.75% in payments in 2021, along with a three month delay in the automatic 2% cut due to “sequestration.”

September 30, 2020

Important Update On Billing For Telehealth For Indiana Medicaid

The IHCP has announced an important change in billing for telehealth services for Indiana fee-for-service (FFS) and managed care plans.

After several complaints from providers who noted that Anthem HIP refused to reimburse at the non-facility rate with POS 02 and modifier 95, the Indiana State Medical Association appealed to the OMPP for assistance. The result is this new bulletin. This change means that you should now bill with POS 11 and modifier GT for all Medicaid plans.

"These changes are required as of October 24, 2020, and through the duration of the public health emergency. However, providers may take advantage of these changes immediately by billing as described, beginning with claims for dates of services (DOS) on or after September 24, 2020."

Unfortunately, there is no mention of any retroactive corrections, but at least for the remainder of the PHE, members can expect to be paid equitably for Anthem HIP patients.

View an updated telehealth summary sheet for Indiana providers (PDF file). 

August 4, 2020

Telehealth and Other Important News

The Public Health Emergency (PHE) scheduled to expire on July 25, 2020 has been renewed for another 90 days. Subsequently, several payers have extended their coverage for telehealth and cost-sharing waivers through either September 30th or December 31, 2020. Please see an updated Telehealth Summary sheet here (PDF file).

ABN Form Updates
The Office of Management and Budget approved the Advance Beneficiary Notice of Noncoverage (ABN) (Form CMS-R-131 (ZIP)) and instructions (PDF) for renewal. You must use the new ABN form with the expiration date of June 30, 2023, beginning August 31. There are no other changes to the form. Visit the ABN webpage for more information. 

July 10, 2020

Updated tools with all the new dates for payers who have extended their telehealth policies are now available:

There are some variations from payer to payer, as you would expect. And in some cases, you will want to check the payer's website for other services like behavioral care where they are extended beyond the regular E/M visits.

Issues with Anthem HIP are being discussed with the Indiana OMPP. While they follow Medicaid guidelines when it comes to place of service 02 and modifier 95, they are paying according to Medicare guidelines and will only reimburse at the facility rate with POS 02. As far as we know, all the other MCEs are paying correctly except Anthem HIP. Continue to bill with POS 02 and modifier 95 so you get some reimbursement. Anthem will deny claims billed with POS 11 and modifier 95.

June 28, 2020

Providers have been asking how long telehealth will continue to be covered with no cost-sharing for patients and the answers are varied at this point. Payers continue to refine their coding guidelines and billers are now looking how to get reimbursed correctly at the full rates that were promised. 

Medicare and Medicaid say telehealth waivers will continue through the end of the Public Health Emergency (PHE). Indiana Medicaid's regular telehealth policy will continue beyond the PHE.

Anthem HIP continues to pay for telehealth visits with 99201-99215, POS 02 and modifier 95 at the reduced facility rate rather than the non-facility rate because they are following Medicaid coding guidelines, but Medicare reimbursement guidelines. The ISMA has been in contact with the IHCP to address this issue, but we have not seen a response yet. Anthem will only pay for telephone-only codes 99441-99443 when they are secondary crossover claims.

Anthem's Coverage for Telehealth Continues

Telehealth (video + audio):
Effective from March 17 through September 30, 2020, Anthem’s affiliated health plans will waive member cost shares for telehealth visits from in-network providers, including visits for mental health or substance use disorders, for our fully-insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible. For out-of-network providers, Anthem is waiving cost shares from March 17 through June 14, 2020. Cost sharing will be waived for members using Anthem’s authorized telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

Telephonic-only care:
Effective from March 19 through September 30, 2020, Anthem’s affiliated health plans will cover telephonic-only visits with in-network providers. Out-of-network coverage will be provided where required. This includes covered visits for mental health or substance use disorders and medical services, for our fully-insured employer plans, individual plans, Medicare plans and Medicaid plans, where permissible. Cost shares will be waived for in-network providers only. Self-insured plan sponsors may opt out of this program.

As federal guidelines continue to evolve in support of the COVID-19 pandemic, Cigna is adopting a position consistent with the federal public health emergency period, which ends on July 24, 2020. As such, Cigna is extending the customer cost-share waivers and other enhanced benefits, including our interim virtual care policy, through at least July 31, 2020.

The guidelines on this page also apply to customers with Individual and Family Plans (IFP). Additionally, on June 1, 2020, Cigna announced that Cigna Medicare Advantage and Cigna Individual and Family Plan (IFP) plans will waive customer cost-share for certain non-COVID-19 services. The press release also announced that Cigna Medicare Advantage is extending all cost-share waivers through the end of 2020, while Cigna IFP will extend these cost-share waivers through the end of the public health emergency period, currently July 31, 2020.

Please note that all other commercial plans (i.e., employer-sponsored plans) continue to have customer cost share for non-COVID-19 services, and cost-share waivers for COVID-19 services are still scheduled to end at the end of the public health emergency period, currently July 31, 2020.

UHC's Coverage for Telehealth Continues
For Medicare Advantage members... in-network telehealth services provided through live interactive audio-video can be billed for members at home or another location through Sept. 30, 2020.

Audio-Only: In accordance with CMS fee schedule changes for audio-only codes, providers will continue to be reimbursed for audio-only visits at the rate they would receive for audio-video or in-person codes. CMS rates for audio-only telephonic evaluation and management (E/M) codes, as well as virtual check-ins (which may be done by telephone) and e-visits for established patients, are being adjusted retroactively for dates of service on or after March 1, 2020.

Audio-only visits and other services not requiring video technology include:

  • Audio-only (telephone) E/M services (CPT codes 99441-99443)
  • Online digital E/M services/e-visits (CPT codes 99421-99423 and HCPCS codes G2061-G2063)
  • Virtual check-ins (HCPCS codes G2010 and G2012)

Please note that Medicare Advantage provider and member incentive programs will not include encounters that are audio only and will require telehealth visits that use live, interactive audio and visual elements.

UHC Commercial

COVID-19 Diagnostic Laboratory Tests

  • Use CPT code 99211 to bill for assessment and collection provided by clinical staff as an incident to service, unless another Evaluation and Management (E/M) code is billed on the same day for concurrent services. This applies to all patients, not just established patients.
  • Submit the CS modifier with 99211 (or other E/M code for assessment and collection) to waive cost sharing.
  • Contact your Medicare Administrative Contractor if you did not include the CS modifier when you submitted 99211 so they can reopen and reprocess claims.
  • Medicare will automatically reprocess claims billed with 99211 that denied due to place of service edits.

CPT update for COVID-19 antigen tests

Code 87426 is intended for use as the industry standard for accurate reporting and tracking of antigen tests using immunofluorescent or immunochromatographic technique for the detection of biomolecules produced by the SAR-CoV-2 virus.

The long descriptors, short and medium descriptors can be accessed on the AMA website.

If there is a specific coding/billing issue you would like us to help with, please contact the IAFP office at (317) 237-4237 or via email