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.

Adjustments and Appeals – What’s the Difference?

When does one file an appeal and when is an adjustment to an insurance claim appropriate?  This can be a confusing situation to a new biller.  When a medical insurance claim is rejected or not paid, usually some action must be taken.  Often it is either that an appeal must be filed or an adjustment to the claim made.
The basic difference between an appeal and an adjustment is:
An adjustment is done when a claim needs to be reprocessed for some given reason.  Appeals are done when there is a disagreement with an insurance company’s decision regarding the processing of the claim.
An adjustment is a request that a processed claim be reprocessed based on new or changed information now being provided.  Basically it is a request for information on the original claim to be corrected with this new information.  An example of the appropriate use of an adjustment would be if a claim was submitted with an incorrect diagnosis or CPT code.  The claim may be denied by the carrier and it is discovered that the claim had incorrect information.  An adjustment would then be filed with the correct information.
Some insurance carriers require the use of a specific form which generally may be found on their website to file an adjustment while others may accept a generic one.   Attach a completed adjustment form to the corrected claim and write “Corrected claim” across the top of the CMS 1500 form.   Circle the item that is being corrected and attach a copy of the EOB.
Appeals are filed when one disagrees with the decision the insurance carrier made in processing the claim.  Often claims are appealed for timely filing or when there is additional information that should be considered.  Appeals are sometimes filed by telephone but often either an appeal form or an appeal letter is required.   As with an adjustment, some insurance carriers require the use of their own appeal form which can usually be found on their website.
An example of when an appeal may be needed is if a claim is initially denied stating the service provided was not medically necessary.   However the provider feels that the service was warranted.  An appeal can be filed with a copy of the medical records and an explanation from the provider as to why the service was medically necessary.
For more information on filing adjustments or  appeals with many example letters, check out our ebook “Denials, Appeals & Adjustments”.  From now through Memorial Day you can get a 20% discount on the book with the coupon code SPRING

“Denials, Appeals and Adjustments” Revised

We are excited to announce that we have completely revised our “Denials, Appeals and Adjustments” including information on ICD10 denials.  We really went through this book adding information and more example appeal letters and adjustment forms.

If you have previously purchased this book, we will be happy to send you a free copy of the new revision!

Send me an email with the email address you purchased the ebook under or the receipt (any proof you purchased) and I will send you a new revision.

Here is more information on “Denials, Appeals and Adjustments”.

If you have not purchased “Denials, Appeals and Adjustments” in the past here is your chance to purchase it on sale.  Use the coupon code DENIALS and get a 20% discount on this book through 4/30/2016.

We have been working hard to revise many of our books and courses as we strive to keep them all current.  Watch for our next announcement of which book and course we will be revising next.

Shop here for ebooks.

Shop here for online courses.

Here is a list of all our online courses.

1.    Introduction to Health Insurance and the Medical Billing Process
2.    Understanding Coding and Modifiers
3.    Life Cycle of an Insurance Claim
4.    Billing Medicare, TRICARE and Medicaid
5.    Billing Blue Cross/Blue Shield, Commercial, Workers Comp and More
6.    HIPAA, HITECH and Regulatory Issues
7.    Reading EOBs, Handling Denials and Filing Appeals
8.    Working with a Practice Management System
9.    Operating a Medical Billing Business
10.    Marketing a Medical Billing Company

Our Free Medical Billing Forum

We offer a free forum for all our readers to ask any billing or marketing questions you may have.  We personally log onto the forum several times a day to answer any questions we can help with.  This forum is an extension of our ebooks.  If you purchase any of our books and still have a question we make our forum available for those questions.  You don’t even have to purchase any our books.  The forum is free to everyone except spammers.

If you haven’t visited our medical billing forum yet, make sure you check it out.

Denial Tip #2 Handle Denials Quickly

We find that many providers’ offices and even billing services tend to put denials aside to take care of them later.  This is a bad idea and can actually end up costing the provider money.  The best time to handle a denial is as soon as the denial is received.

Some insurance carriers have time limits on when denials must be handled.  For example, one of our local insurance carriers only allows sixty days from the date of the denial for a denial to be handled.  If an appeal needs to be submitted, or information must be corrected, it must be done within sixty days or it will not be accepted.  Often when the denial is put aside more time passes than intended.  This can lead to missing the time limit on handling the denial.  Maybe there is still time to file the appeal or submit the information, but there is no time for research or gathering the information needed for the appeal or correction.

Another reason it is not a good idea is that the claim is still showing as outstanding in the practice management system.  This means it is still showing up on aging reports and may result in unnecessary work being done.  If the denial is set to the side with no notations made in the system, the person working the aging report may not realize that the claim was denied and call to check on the status.  This would be a waste of time since the claim was denied and the information on the denial was obtained.

Here at Solutions Medical Billing, we take the information of any denied claims and put it right in our work folders for that individual provider.  When the claims and payments are entered for that provider the denials are worked as well right then.  If a denial is set aside or put in a drawer it is much too easy to let it fall through the cracks.

Much money is lost by providers every year on denied insurance claims.  Handling denials quickly will help reduce the amount of money that is lost.

Denied Insurance Claims – Tip Series 1

Denied insurance claims seem to be one of the areas that many medical offices struggle with.  They either do not have the time to deal with them, or they don’t know what to do with them.  In any case, denied insurance claims can cause much loss of revenue.  If not handled and not handled properly, the provider can lose out on income that is due to him.  We are starting a series of tips on handling denied insurance claims.  Our first tip is on making sure that all claims affected by a denial are corrected and resubmitted.

Tip #1:  Make sure All Claims Affected are Corrected and Resubmitted:

One thing that tends to get overlooked when handling denials is to check for other outstanding claims on a patient when a denial is received that will affect all claims out on a patient.  For example, if a denial is received for a patient because the patient’s insurance has changed then all claims submitted for that patient after the change of insurance will need to be corrected.

Many times a biller will receive a denial for one particular date of service, make the correction and resubmit just that one claim.  They don’t take the time to look and see if there are any other claims out for the patient that also need correcting.  As I’m writing this I’m thinking it would be a no brainer, but in all of my years of training this is actually something that needs to be taught especially with new or inexperienced billers.  They just don’t think about the whole picture without being taught to.

It is not uncommon for us to be checking over the work of a newer or inexperienced employee to find that they were informed of an insurance change on a patient.  The information that they received was for one specific date of service.  They corrected that one claim and resubmitted.  What they didn’t do was to look at the patient’s file to notice that there were several other dates of service out there also submitted with the incorrect insurance information.  Those claims also need to be corrected and resubmitted.

We also teach them to look at the other family members as well.  If the insurance changed for one of the children and the policy is through the parent, it most likely changed for everybody in the family.  Looking into it now can save much work later on and even prevent money from being lost.

If the denial is for something that is only specifically related to the claim in question then this is not an issue.  But if the denial is for something that would affect all claims for the patient and/or family, then it is important that the biller take the time to make sure all claims are corrected and resubmitted and not just the one that received the denial.

Issues that may affect multiple claims for a patient:

•    Change of insurance carrier
•    Change of insurance ID number (Blue Cross Blue Shield often changes ID numbers!)
•    Truncated or invalid ICD code (this can affect multiple claims for specialties such as mental health, PT, chiropractic and others)
•    Invalid patient information such as date of birth or misspelled name

For more information on Handling Denials see our online course:  “Reading EOBs, Handling Denials and Filing Appeals”

Secret of Reversing a Denied Insurance Claim

Medical insurance claim denials can be very costly to the medical office and to a billing service. Denied claims must be investigated to see why they were denied and what must be done for the provider to be reimbursed for the service. Some denials are legitimate. The services may simply not be covered under the patient’s insurance plan. Many are in error or may be due to an issue that can be corrected and then reprocessed by the insurance carrier. If an insurance claim is denied but you believe it should have been paid there is one secret to the successful resolution of that claim. That secret is…


It may take as many as six resubmissions and/or up to eight phone calls as we recently experienced but you must stay on top of it to get final resolution. One of our favorite providers saw a patient for several counseling sessions and the claims came back denied stating the patient had no coverage with that plan. We reported this information to our provider who then checked with the patient. The patient called United Healthcare and straightened out the coverage issue. The provider called us back and advised us that the issue was resolved and asked us to resubmit all of the visits. All claims were resubmitted but three weeks later another denial arrived still stating the patient had no coverage.  After speaking to a customer service representative we were told that the patient is still not a member of that plan. We explained that the patient had called and straightened out this issue.   After a lengthy hold, the customer service representative returned and advised us that the patient did indeed have coverage. We were told to resubmit the claims again.

After not hearing on these claims for another month we called back and were told the claims were now denied due to the CPT code. They stated that the provider was not authorized to bill for the extended visits. However the provider did have the appropriate authorization. The customer service representative advised us that the claims would be sent back for reprocessing. We heard nothing for another month and called back to find that the claims were not put back through for reprocessing. Three weeks later we called back and were told that they were still being reprocessed. A month later we received a denial stating the claims were denied by the Medicare system.

We called back and explained that these were not Medicare claims and should not have gone through the Medicare system. The representative offered to send them back for review. A month later we called back to find that they no longer have a record of the claims with the appropriate id number. They asked us to fax them in. Faxed, called, verified receipt! A month later we got paid for 2 of the six claims. I would like to say that it was finally resolved, but we are still waiting for payment on the final four claims which of course we called back on once more.

Obviously we will not recoup all the expense of this lost time in tracking these claims. But this is work that must be done. It all averages out in the end. The bottom line is that it may be necessary to follow up multiple times on problem claims. If this is not done much money can be lost. Hopefully you never run into one this involved.

If you are having issues with denied claims and do not know how to get the best results, check out our ebook “Denials, Adjustments and Appeals”