IMPORTANT NEWS FOR MEDICARE PROVIDERS!
New Rules For Claims Coding
By Barbara Griswold, LMFT (August 5, 2024)
Do the folks at Medicare just ENJOY making our lives difficult? It would seem so, as they’ve changed their rules once again, this time with a new directive about telehealth modifiers.
A little modifier history: For years Medicare has been directing therapists to use the 95 modifier after the CPT code to indicate the session was a telehealth session. Then they developed the modifier 93 for phone sessions, leaving 95 for video. Then in January 2024, the new directive came down that NO modifier should be used for telehealth, except when the therapist was at a hospital and the patient was at home (to see that directive, click here).
Now, in a recent Medicare Change Order, Medicare is changing their mind, saying they DO want these modifiers in all telehealth billing. According to the Change Order, Place of Service codes now “must be paired with the appropriate telehealth modifier (modifier 93 for audio-only and modifier 95 for audio/video).”
In their report on this change, The Center for Connected Health Policy (CCHP) confirmed that “previous guidance had seemed to limit the continued use of these modifiers to institutional provider claims only, therefore this is also an important clarification to highlight.” For more info, read the CCHP article (click here) and the actual Medicare Change order (click here, scroll to page 18, in red).
“Why doesn’t my regional Medicare Administrative Contractor (MAC) know anything about this?” Your regional MAC may be clueless about the new directive. Think of federal Medicare like the big bosses on the 25th floor of a huge company. When they make a decision, it may take some time for the message to filter down to folks in the mailroom (the regional MACs). We see this pattern whenever Medicare makes billing and coding changes. If they deny this change, refer them to Medicare Change Order #13582.
“Have there been any changes in Place of Service (POS) Codes?” Hopefully, you got the message that in January 2024 Medicare changed their guidance on Place of Service (POS) codes, also. This was verified in this Change Order. POS codes are the two-digit codes that tell the plan where the service took place. During the pandemic and throughout 2023, Medicare instructed therapists to use Place of Service code 11 (office) for all Medicare sessions, even for telehealth. If instead you used one of the two telehealth POS codes — 10 when the client is at their home, or 02 when the client is somewhere else – it resulted in underpayments. But as of 1/1/24, Medicare told us to begin using telehealth POS codes for telehealth sessions. However, keep in mind that unlike most private health plans, Medicare pays a lower “facility” rate for the 02 Place of Service code. So, if you got paid a lower amount, check the POS code you billed.
“When does this change take effect?” According to the Change Order and the CCHP, this guidance is retroactively effective back to January 1, 2024. What does this mean for you, if you stopped using modifiers, as instructed? Or what if you have been using the modifiers all year? For more on this story, and what to do if you haven’t been putting modifiers on your Medicare claims, read a more in-depth article on this issue with tips from Medicare billing expert Susan Frager – click here.