Telehealth Billing Changes for Coming in 2022

The onset of COVID-19 caused most major insurance carriers to suddenly not only allow telehealth, but to reduce the restrictions. Telehealth has been around for years, but is clearly much more common today. With COVID-19 settling into somewhat of a norm now, we are seeing that insurances are starting to change the rules regarding telehealth. Even though telehealth was utilized in almost every area of medicine, the mental health community definitely was one of the largest specialties providing telehealth services. Patients receiving mental health treatment prior to COVID couldn’t just stop, and COVID brought on the need for many others to being treatment. While providers across the nation were forced to close their office doors, mental health providers scrambled to find a way to continue treatment for their patients. Telehealth was the best option.

Medicare recently announced some billing changes for 2022. According to the new rule, effective January 1, 2022CMS will require providers to use a new POS code for services provided to patients by telehealth while the patient is in their home. The following are the POS codes for telehealth services effective January 1, 2022.

POS code 02 – is for Telehealth Services Provided Other than in the Patient’s HOme.

POS code 10 – is for Telehealth Provided in the Patient’s Home

POS code 10 does not apply if the patient is in a hospital, skilled
nursing facility, or assisted living facility. It only applies if the
patient is receiving the services from their home.

The Office of the Inspector General of the US Department of Health and
Human Services recently released a data snapshot that showed that most
Medicare beneficiaries (78%) who received telehealth health services
from a psychologist had an established relationship with that provider
prior to receiving telehealth services. But several Medicare
beneficiaries (22%) began treatment with a psychologist through
telehealth without having an established in person relationship. It is
possible that the rules may change in the future requiring at least one
in person meeting in a certain time frame in order to receive telehealth

The expansion of telehealth services has been essential to maintaining
access to care for many patients during this pandemic. It is something
that I believe will always be present in healthcare going forward. But
the rules will continue to be revised as time goes on. We must keep up
to date with all information pertaining to telehealth. We will continue
to report any changes as we become aware of them.

Will Telehealth Continue When the Health Crisis is Over?

Telehealth has been around for decades and can be traced back to the late 1800s.  But telehealth as we know it today is very different.  Prior to COVID-19 telehealth was only covered in situations where patients had difficulty getting access to medical care due to geographical constraints.  But in March 2020, insurance carriers started allowing telehealth for all patients to try to stop the spread of COVID-19.  They also allowed telehealth services to be audio only, where in the past it would require both audio and video.

So the question is, how long are insurance carriers going to continue to allow telehealth with these relaxed rules?  CMS is proposing that they be allowed until 12/21/2023.  In that time they plan to conduct analyses for permanent expansion of telehealth services.  Most expect that commercial insurances will follow CMS’s lead. 

Currently telehealth services have only been approved through September 30, 2021 but President Biden plans on extending it until at least December 31, 2021.  CMS plans on seeking additional requirements for extending telehealth permanently such as:

  • Requiring in person behavioral health visits at least every 6 months
  • Allowing audio only services to established patients with technological restraints
  • Introducing a new modifier to identify audio only services

It doesn’t appear that COVID-19 will be completely gone any time soon, so it only makes sense to continue telehealth services.  People who are high risk with underlying medical conditions can reduce the amount of exposure by receiving telehealth services for behavioral health services or follow up care.  Also, patients who are experiencing some form of symptoms but still need to be seen, can be seen without exposing others.  There are a lot of positive reasons to continue telehealth. 

Only time will tell for sure, but for now it looks like telehealth, in some form or another, is here for the long haul.  However, providers need to pay attention to changes to make sure their services are going to continue to be covered.  One can’t assume that what is covered now, is what will be covered tomorrow.  Make sure to stay up to date with the insurance carrier’s regulations.

6 Steps To Effectively Appeal A Claim

In a perfect world all submitted claims would be processed and paid, on the first submission.  But anyone in the billing world knows that is not how it works.  Many claims are processed and paid on the first submission, but some are not.  The ones that are not need to be dealt with. Some just need to have a minor correction and resubmitted, but some need to be appealed.

What does it take to successfully appeal a claim? 

  1. Have a process in place  –  knowing how to file an appeal and having a process in place for the most commonly filed appeals is key.  It will save time and frustration.  When a process is already in place, it makes preparing and filing the appeal much easier.
  2. File the appeal as quickly as possible  –  most insurances have a time limit on when appeals can be filed.  The quicker the appeal is filed, the better.  If for any reason the appeal was not received, it can be resubmitted if there is enough time.  If the appeal is filed quickly, it allows for these types of issues.
  3. Identify the reason for the appeal  –  make sure that the appeal is noted as an appeal and that the reason for the appeal is clearly stated on the first page of the appeal.  If the insurance carrier has a specific form, use that form and make sure to check the appropriate reason for appeal.  If no form is available attach a letter or cover sheet identifying that the claim is being appealed and why.
  4. Attach any/all documentation to support the appeal  –  the more documentation supporting the appeal, the more likely to receive a favorable response.   For example, on a timely filing appeal, attach any clearinghouse reports, practice management reports, and/or USPS reports showing when the claim was submitted.  Also attach a letter explaining any delays.  When submitting an appeal because the doctor disagrees with a service/procedure being denied for medical necessity, attach all medical records, a statement from the doctor explaining his/her argument, and any medical documentation supporting the service/procedure for the diagnosis.
  5. Note the patient’s file  –  make sure to document when the appeal was filed and how it was filed.  It is also a good idea to keep a copy of the appeal (electronically) so that it can be referenced if needed. 
  6. Follow up  –  If a response to the appeal is not received in a timely manner, follow up with the insurance carrier to find out the status of the appeal.  Sometimes insurance carriers will state that they did not receive an appeal.  If a follow up is done, the appeal can be resubmitted.  Don’t just sit back and wait for a response.  Most insurance carriers respond to appeals within 30 days. 

Many providers do not appeal denied claims.  This can cause them to lose a lot of revenue.  Appeals do not have to be complicated.  Once a system is in place it doesn’t take that much effort.  Follow the six steps above and stop your practice/provider from losing revenue that they are entitled to.

Update on place of service and modifiers for telehealth…

As the COVID-19 Pandemic continues, providers and billers look for updates on coding for telehealth services.  Prior to COVID-19 the average biller didn’t have to know anything about telehealth billing but post COVID-19 almost all billers have had to learn.  So where are we almost eighteen months later?  Basically in the same position. Each insurance carrier has their own guidelines for billing telehealth services.  Most of the restrictions have been lifted allowing almost all providers to provide telehealth services.  The insurance carriers were scrambling to set up guidelines for billing and they didn’t all set up the same.  Here are some of the ones we know:

Medicare requires that telehealth services be billed with a place of service code of 11 and a 95 modifier.

TRICARE requires that telehealth services be billed with a place of service code of 02 and a 95 modifier.

CIGNA  requires that telehealth services be billed with a place of service code of 11 and a 95 modifier.

MVP  requires that telehealth services be billed with a place of service code of 11 and a 95 modifier.

Aetna requires that telehealth services be billed with a place of service code of 02 and a 95 modifier.

Health First requires that telehealth services be billed with a place of service code of 02 and a 95 modifier.

Emplem requires that telehealth services be billed with a place of service code of 11 and a 95 or a GT modifier.

Most BCBS plans requires that telehealth services be billed with a place of service code of 02 and a 95 modifier.

There is no way to list them all.  Bottom line it is important to figure out how the carrier that is being billed requires it to be submitted and follow those rules.  If a claim is denied, check with the carrier to see what their requirements for telehealth services are and refile the claim.

7 Steps To Improve Billing And Collections

We get a lot of questions on how to improve billing and collections.  It is crucial in today’s world to make sure that all that is due is being collected.  Providers have added expenses to ensure patient safety in this pandemic state we are still in, and many offices cannot see the number of patients in the same amount of time, that they were seeing pre-pandemic.  It is important that nothing is slipping through the cracks. 

There are several things that can be done to improve billing and collections that start before the patient is seen, and continue on through until the claim is paid. 

  1.  Insurance Verification  –  we cannot stress enough how important it is to make sure the patient is covered under the plan/policy that they are presenting with.  There is so much confusion out there today with all of the Medicare Advantage Plans, and Medicaid Advantage Plans, not to mention patients changing jobs or employers changing insurance plans.  It is crucial to make sure the correct insurance is being billed from the beginning, and to make sure the provider accepts the patient’s plan and does any pre-authorization that may be required.  Since most insurances allow online access, this is an easy task.
  2. Accuracy inputting patient data  –  make sure the front office staff (or whoever is responsible for inputting the data) is careful when inputting the patient information.  Simple typos can be very costly and time consuming to correct.
  3. Verify information  –  when repeat patients come in, verify their information.  Make sure they have the same insurance plan, and the same demographic information.  Correct data makes for clean claims.  Incorrect data can cause delays or even denials of claims.
  4. Collect copays  –   copays should always be collected at the time of service.  It is more likely that a provider will be paid if the money is collected in the office.  Also, it costs money to send out patient statements.  If the copay is collected at the time of service it eliminates the chance that the provider will not get paid, and cuts costs of sending out statements unnecessarily. 
  5. Submit claims timely  –  we still hear of billers that hold claims before submitting.  There are different reasons behind why.  Some just don’t have time, while others believe that sending a bunch together is more efficient.   However, the quicker you submit the claim, the quicker you will learn of a problem if there is one, and the quicker payment will be received. 
  6. Check clearinghouse reports regularly  –  most clearinghouses provide daily reports of denials and rejections.  These should be checked regularly.  The quicker a denial or rejection is handled, the more likely it is to be corrected. 
  7. Work Aging Reports  –  most medical offices lose money on unpaid claims because they are not working aging reports regularly.  It is important that an aging report is run, and any claims outstanding over 30 days are checked on.  Most clearinghouses (at least the good ones) allow for claims to be checked through the clearinghouse.  At the very least they will indicate if the claim was accepted by the insurance carrier.  Most will provide payment information or the reason the claim wasn’t paid if it was denied.  Denials should be caught before the aging report, but if they slip through they will get caught now.  The aging report is the last step for catching money before it is lost.  Unfortunately many offices put this job on the bottom of the to do list and it often gets left untouched.  Offices that are not working the aging report regularly can be losing up to 30% of their revenue. 

Billing and collections is one of the most important jobs in the office.  It is right up there next to treating the patients.  If the providers are paid for their services, they won’t be able to continue treating patients.  Following the 7 steps above will help make that process as smooth and efficient as possible.

Billing for COVID-19 Vaccines

A year ago billers were scrambling to learn how to bill for COVID-19 testing.  Now we are scrambling to learn how to bill for COVID-19 Vaccines!  CMS, the AMA, the WHO and the CDC have had to scramble as well.  First to come out with ICD 10 codes for COVID-19, such as Z11.52 for encounter for screening for COVID-19 and Z20.822 for contact with and suspected exposure to COVID-19.  And to come out with CPT codes for COVID-19 testing, and now to come out with CPT codes for the vaccines.

So let’s get right to it.  As with all vaccines there are two codes for each vaccine.  The first code is for the actual vaccine or the substance that is injected into the patient.  The second code is the administration code, which is to cover the cost of the supplies, and the manpower to administer the vaccine.  There is a separate allowance for each and it is important that both codes are billed so that the provider is reimbursed appropriately.  The vaccine charge is just to cover the cost of the actual vaccine that is being used.  The administration charge covers the providers’ materials and time.

They introduced separate codes for each manufacturer and a separate administration code for each dose.  With the Pfizer and Moderna vaccines there are two doses for each vaccine.  The Johnson & Johnson vaccine is only a one dose vaccine. 

Currently only the three vaccines are available in the US.  The Janssen, or J & J vaccine was on a pause for almost two weeks, but has been reinstated.  There is another vaccine being used in Europe by AstraZeneca but it has not been approved yet in the US.  The AstraZeneca vaccine is also a two shot vaccine.

The new CPT and HCPCS codes that have been introduced to cover the vaccine are as follows:

91300   –             Pfizer COVID-19 Vaccine  (the actual substance that is being injected)

0001A   –             administration for the first dose of the Pfizer COVID-19 vaccine

0002A  –              administration for the second dose of the Pfizer COVID-19 vaccine

91301   –             Moderna COVID-19 Vaccine  (the actual substance that is being injected)

0011A   –             administration for the first dose of the Moderna COVID-19 vaccine

0012A  –              administration for the second dose of the Moderna COVID-19 vaccine

91302   –             AstraZeneca COVID-19 Vaccine  (the actual substance that is being injected)

0021A   –             administration for the first dose of the AstraZeneca COVID-19 vaccine

0022A  –              administration for the second dose of the AstraZeneca COVID-19 vaccine

91303   –             Janssen (J&J) COVID-19 Vaccine  (the actual substance that is being injected)

0031A   –             administration for the first dose of the Janssen (J&J) COVID-19 vaccine

The ICD10 code that should be used for all vaccines is Z23 for encounter for immunization.  The US Government is providing the vaccine free of charge to all people living in the US so the charge for the actual vaccine is only $0.01.  The national payment allowance for the administration is currently $40.  The Medicare allowed amounts for the administration vary depending on the area of the country and whether it is the first or second dose of the vaccine.  It also depends on when the vaccine was administered. 

It really isn’t too complicated and is much like billing for other vaccinations.  Hopefully this article will help clear up any confusion!

Telemedicine Billing One Year Later – Where are we?

When COVID hit telemedicine was something that was only allowed in rural areas, or areas where patients had limited access to medical care.  But COVID made telemedicine a necessity.  Providers and billers were scrambling to figure out how to bill for telemedicine and insurance carriers were scrambling to figure out how to allow for it. 

Once COVID-19 hit the united states nany medical office were forced to temporarily close.  No one knew (at that time) how long these closures would last.  Most primary care doctors remained open but were only seeing patients with urgent conditions.

Most specialty offices such as eye doctors, physical therapists, urologists, dermatologists, chiropractors and others were forced to close.  The problem was that patients still had other conditions that required treatment.  Disease didn’t stop due to COVID-19.  People still had high blood pressure, diabetes, conjunctivitis, cancer, etc.  When the closures were first announced it was implied that it would only last for a couple of weeks.  But very quickly it became evident it would be longer.

Insurance carriers were forced to change coverage guidelines.  Patients needed to be seen.  Especially patients seeking outpatient mental health care.  Mental health services have been steadily increasing throughout the last several years.  COVID-19 caused many more Americans to seek mental health care.  Patients that were already in treatment needed to continue being seen, and these new patients also needed to be seen.

Insurance carriers and providers had to find a way to provide medical care to patients while protecting both patient and provider.  In cases where patients had no choice but to see providers in person, they had to rely on protective gear such as masks, shields and gloves.  But in cases where a patient did not have to be seen in person, telemedicine made the most sense.

Insurance carriers that previously covered telemedicine, but with restrictions, basically lifted those restrictions.  Insurance carriers that did not previously cover telemedicine began allowing it immediately.  Some carriers even went as far as to cover the patients’ responsibility.  For example, if a patient saw a psychologist pre-COVID-19 and had a $25 copay but now saw the same psychologist for a telemedicine visit after March of 2020, they would pay the entire allowed amount.  The patient would not have to pay the $25 copay and the provider would be reimbursed for the entire allowed amount.

So where are we one year later?  Telemedicine is still very much being utilized, especially in the mental health field.  Vaccinations have started, and the infection rates are way down, but some patients are still high risk, or just afraid to expose themselves.  Insurance carriers are still allowing providers to utilize telemedicine.  Honestly, in my opinion I think telemedicine is here to stay at least on some level. 

Many providers were already pushing for telemedicine prior to COVID.  It is utilized in other countries and by insurance carriers.  I believe COVID pushed us forward in this area and now that we’ve arrived we won’t be looking back.  Face it, telemedicine can be very effective.  There are many medical visits missed each year because patients don’t feel well, don’t have transportation,  don’t have a babysitter, or many other reasons.  With a telemedicine option there won’t be as many cancelled appointments or missed appointments.  It can also allow providers to practice more efficiently. 

Of course there are certain fields and certain medical conditions that require face to face contact.  But there are many other situations where telemedicine works great.  With the way life is today, between COVID and simply the craziness of life telemedicine can make things easier on both ends.  I don’t believe it will be going away anytime soon!

Options for Out of Network Providers

Many providers opt to take the road of staying out of network, or not participating with insurance carriers. This has been going on for many years. Usually it tends to be specialty providers such as mental health providers but with the increasing changes of insurance billing more and more providers are opting to take this path.

What does that mean for the provider and the patient? Well for the patient it means that they need to verify if their insurance provides out of network benefits. If they do have out of network benefits, then the claim may be submitted and payment, if any, will be made directly to the patient. The provider may not necessarily file the insurance claim for the patient. They may simply provide the patient with a statement that will allow the patient to submit the claim themselves. Some, although in our experience, it is rare, actually still submit the claim even if they are not in network. For the provider it may mean that the patient may choose to go to a different provider that is in network with their insurance.

Are there any other options for these providers to assist the patient with the claim submission process while remaining out of network and not incurring expensive overhead costs such as office staff to submit the claims? We actually were introduced to a company that developed a phone app to assist patients with submitting out of network insurance claims! The app which is free to download, allows a patient to take the statement given to them, enter all of the information into the app with just a few questions, and submit the insurance claim to their insurance carrier. Then they receive notifications when the claim is sent, and when the claim is received by their insurance so that they can easily follow up.

The app actually allows providers to register themselves (no charge!) so that if their patients use the app the provider will come up on a search and the patient can simply select them without having to enter the provider’s demographics, NPI or tax ID. They also provide handouts for the out of network providers to give to their patients, or put out in their office to walk the patients through the process. There is even an option for providers to pay a small monthly fee that allows their patients to submit claims using the app at no charge to the patient. So if the provider would like to submit claims on behalf of the patient but they don’t want to have people on staff to handle that, they can incur the cost and it’s much cheaper than having an employee.

This may seem like an odd topic for a billing service to be discussing. After all, we are the ones doing the billing for most providers. However, we often come across a provider that is out of network, and our service really doesn’t make sense for them. Or we all know that patient that has a provider they love, but the provider is out of network and they need to submit the claim on their own. My daughter used to go to an out of network dentist that she absolutely loved. She had a slight fear of dentists and he was amazing. I wish this app had been available back then!

So if you know any out of network providers, or if you have a friend or family member that struggles with submitting their own claims, you can find out more about this program at

Outsourcing Vs. In-house Medical Billing


After 25 years in the business, we still have many people ask us why a provider should outsource vs keeping the billing in house. It is something that new billing services need to understand in order to succeed. If a billing service doesn’t understand their worth then they will never be able to sign up clients. And both new and established billing services need to recognize when a provider’s office has an in house billing system that is working. If they have a billing system that is working and your service won’t benefit them it’s not a good idea to enter into a contract.

In our experience a provider won’t usually agree to sit down with a service if their current system is working efficiently. They usually only meet with an outside service if they have a problem. But it’s important to recognize when outsourcing makes sense. In order to determine if outsourcing makes sense a cost analysis should be done. Here are some things to consider when performing a cost analysis:

1. Billing Department/Staff costs – This would include the salaries of the employees working in the billing department. If there are employees with multiple functions (billing and front desk, etc) then estimate the amount of time spent on billing (50%, 75%) and take that percentage of their salary. It would also include healthcare costs (if supplied), payroll taxes, vacation time, sick time, disability, office space, and supplies (desk, printer, paper, ink, phone, postage, forms, etc). Basically anything that it is costing the office to have the employee in the building.
2. Software/Hardware costs – Practice Management Systems range anywhere from a few hundred dollars to several thousand. This cost also depends on if the provider purchases server software or if they ‘rent’ software monthly. If the software requires updates, or support those costs need to be considered as well. There is also the computer costs, as well as maintenance on the computers. The cost of any printers, scanners and/or photo copiers would also be considered. These items may still be required if outsourcing however the costs will go down because the usage goes down.
3. Claim Processing Costs – This would be clearinghouse fees, envelopes, postage for paper claims and patient statements, and any other costs associated with actually submitting the insurance claims.

Most medical billing services charge a percentage of the amount collected and studies show that the nationwide average is 7%. In some states charging a percentage is considered fee splitting and is illegal. Whether the billing service is charging a percentage or a flat fee, the costs are usually around 7% of the practice’s revenue.

Studies do show that on average the percentage of revenue collected when using an outside service is higher than the percentage of revenue collected in house. In our personal experience we have seen that the providers that switch from in house to using our service have seen increases in their revenue. In some cases it has been a very large increase and in one in particular it was 60 percent.
Studies also show that 25%-30% of medical office revenue is lost to improper billing. $59% of in house billers do not review EOBS and 55% of in house billers do not appeal denied claims. Our experience supports these studies. We find that most in house billers do not run or work regular aging reports and do not appeal denied claims. They simply send out the billing and accept whatever comes in. Most medical offices have a high turnover of staff and the providers are not involved with the billing so they are unaware of the amount of revenue being lost.
If considering outsourcing a provider should look at all of the costs to billing in house, what their current average revenue is, and how much it would cost to outsource. They should also consider how much they are collecting of the amount being billed out to see if there appears to be an issue. If the in house billing system does not seem to be efficient or effective outsourcing may be a good move. Next newsletter we will go over what a medical office should look for when interviewing a medical billing service.

3 Key Strategies to Improve your Revenue Cycle Management for Patient Responsibilities

With patient deductibles and copays being higher than ever it is important that providers have efficient and effective systems for collecting what is due. There are many different elements involved with patient care and the billing of patient care. It is like a machine with a lot of moving parts. If one part isn’t moving properly it can mess up the entire system. Here are three key strategies to help improve an office’s efficiency and effectiveness of collecting the patient responsibility for their services.

1. Automate – Believe it or not there are still providers out there who do a lot of their revenue cycle management by paper. With the technology we have today that is hard to believe but we are in offices all of the time and we are still seeing providers with paper systems. One of our offices doesn’t have internet connection on their front office computer and the PM system is from 2004. It is near impossible to have an efficient and effective paper system. It may be effective but it won’t be efficient. You don’t have to break the bank to automate. There are many affordable options out there. Revenue cycle automation can significantly reduce the administrative burden on an office.

2. Improve Front-end Processes – Errors on the front end cause a ton of work on the back end. There are a lot of things that can be done on the front end to prevent errors that will save a lot of work on the back end. It is estimated that approximately 90% of claim denials are preventable. Most of these denials could be prevented with good front end processes in place since missing or incorrect patient data is one of the main denial reasons. Making sure the patient’s data is accurate when collected is one huge way to prevent denials. Claims that are denied often go unpaid which prevents the provider from not only collecting anything due from the insurance carrier but also from the patient. Automating patient registration, benefit verification and prior authorizations can greatly improve accuracy of claims.
3. Improve the patient billing process – Many offices do not even send regular patient statements. Patient statements should be sent at least once a month. Technology today can allow an office to send patient statements by email which can cut down on costs tremendously. It cuts out printing costs, postage costs, and supplies such as paper and envelopes. It also saves on time in stuffing the envelopes. There are also services out there that can receive patient bills in a file and they print and mail them. Usually their cost is less than it costs an office to mail the statements and they provide a lot of options such as statement layout and customization.

With the patient responsibilities becoming larger and larger it is crucial that providers are able to collect on those amounts due. Implementing procedures and systems to make the process more efficient will help cut down on amounts becoming uncollectable and will improve the provider’s overall revenue management cycle. Technology can help to bring the revenue cycle up to speed in an evolving industry.