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Providing no-cost vaccinations to patients during the pandemic has its own set of challenges, including collecting reimbursement. The Department of Health and Human Services (HHS) has created the COVID-19 Coverage Assistance Fund to help providers get paid while staying compliant.

In this month’s “3 Things to Know About RCM,” we’ll provide information about this new program, share advice on increasing claim accuracy, and share information about minors and confidentiality.

New COVID-19 Assistance Fund Supports Urgent Care Vaccine Providers

COVID-19 has broken all the tried-and-true rules for reimbursement. While some COVID-19-related services are covered for patients with insurance, COVID-19 vaccines must be provided to all patients with no out-of-pocket expense.

To reimburse practices for this service, the U.S. Department of Health and Human Services (HHS) created a new program to cover the cost. The COVID-19 Coverage Assistance Fund (CAF) is funded by the Provider Relief Fund Program and overseen by the Health Resources & Services Administration (HRSA). It is only for COVID-19 vaccine administration fees.

It’s easy to enroll with no contracting and credentialing involved. Practices need to enroll in this program and add all their providers. To support your claims, Experity will need access to check claim status.

Providers must agree that:

  • They have submitted a claim to the patient’s primary health insurance plan and there is a remaining balance from that health insurance plan that either does not include COVID-19 vaccination as a covered benefit or covers COVID-19 vaccine administration, but with cost sharing.
  • They have verified that no other third-party payer will reimburse them for COVID-19 vaccine administration fees for that patient encounter, or other patient charges related to that COVID-19 vaccination, including copays for vaccine administration, deductibles for vaccine administration, and co-insurance.
  • They will accept defined program reimbursement as payment in full.
  • They agree not to balance bill the patient.
  • They agree to program terms and conditions and may be subject to post-reimbursement audit review.

Claims submitted any time since December 14, 2020 are eligible and will be reimbursed at Medicare rates on the date of service. Expect reimbursement via ACH payment within five days if claims are clean.

Increase Your E/M Claim Accuracy with These AMA Clarifications

The American Medical Association (AMA) recently updated the guidelines for 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). This should clear up confusion for coders who are navigating the best ways to apply new medical decision making (MDM) guidelines to determine level of service.

Focus on these three highlights, especially if you’re a pediatrics coder, as well as some expert insights for additional context.

Clarified Category 1 Data Point Guidelines

Coming into 2021, the late clarification by the American Medical Association (AMA) that providers could not count unique testing (tests billed with their own CTP® code) as an element of MDM under amount and/or complexity of data to be reviewed and analyzed caused some controversy around urgent care providers.

New clarification by the AMA confirms that you can count test analysis as a Category 1 bullet when it is “in the thought processes for diagnosis, evaluation, or treatment.” You can count each unique test that you perform in your office as part of the data analyzed to address the patient’s problem as long as the physician effort is subsumed by the E/M.

In other words, you can get Category 1 credit under MDM if you order the test and bill for it, but it is exclusive to results-only testing.

Defining Risk

One of the biggest changes in this round of AMA revisions is regarding medical decision making (MDM) for moderate- and high-level risk of complications and/or morbidity or mortality of patient management.

The AMA clarified that the risk of the risk of complications and/or morbidity or mortality of patient management at an encounter… is distinct from the risk of the condition itself. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.

Keep Reporting Office/Outpatient E/M with Preventive

More confusion, especially for pediatrics coders, is whether the guidelines for reporting sick visits with preventive visits have changed. The simple answer is no. You will continue to report the two services when performed together in exactly the same way as you have always done. Modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] will still need to be appended to the problem assessment of the E/M visit.

But remember, time spent cannot be counted twice. If time is used for selection of an office/outpatient E/M code level, the time spent on the preventive service cannot be counted toward the time for the work of the problem assessment.

Coding Alert: Even though the AMA released this latest series of revisions on March 9, 2021, the effective date for the changes is Jan. 1, 2021.

See AMA code and guideline changes for the latest information.

Keeping Up with State Laws on Telehealth

Urgent Care providers across the U.S. leaned on telehealth services throughout the COVID-19 surge to manage the needs of their patients with less risk. In some cases, it helped them keep the doors open. While the need for these services has been supported by federal regulatory changes to ease the burden on providers, these changes haven’t necessarily translated to individual states.

Here’s what you should know:

On April 15, HHS Secretary Xavier Becerra extended the PHE for another 90 days, effective April 15, 2021. Under this PHE extension, HHS and its partner agencies can continue to offer the popular federal telehealth waivers and flexibilities to providers – but that doesn’t mean the state laws must follow the same requirements.

Providers offering telehealth are subject to licensure rules of the state in which the patient is physically located at the time of consult. Individual states determine the telehealth standards and requirements of providers practicing in their state.

During the pandemic, many governors relaxed licensure requirements allowing physicians to offer telehealth services in states where they are not licensed to help stop the spread of COVID-19. But in some cases, the state definitions for telehealth services (and the documentation required) are not aligned with other states. In fact, some state regulations are still being changed and clarified.

Right now, payments are relatively uniform with certain E/M visits being reimbursed for the same amount whether they’re performed virtually or in person; however, that’s not always the case. In some states, lawmakers are now debating whether to eliminate payment parity.

In addition, HIPAA regulations regarding telehealth enforcement discretion during the public health emergency won’t last forever. The rules didn’t actually change, but instead, enforcement discretion was expanded. It’s likely that before long, probably when the PHE expires, previous enforcement requirements will be reinstated.

Tip: Keep your eyes on telehealth state and federal regulations to ensure accurate claims and compliance.

Interested in more urgent care tips, best practices, and industry updates? Check out our April and May installments.

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