Urgent Cares Should Prepare for Telehealth Claims Audits

Optimizing your revenue is more challenging than ever. Coding is complicated, the rules keep changing and pre-pandemic processes just aren’t effective. At Experity, we’re committed to keeping you informed about the biggest things happening around urgent care billing, coding, and compliance.

Each month we’ll be checking in with our RCM experts and posting a quick recap of the top three things you need to know to stay current and profitable as we navigate industry change and external influence.

Annual Update to ICD-10 Codes Go into Effect October 1.

With the annual update to ICD-10 codes going into effect next month, urgent care operators should take note of the guidelines. Get the full details at ICD-10-CM Official Guidelines for coding and Reporting FY 2021 (October 1, 2020 ” September 30, 2021).
Coding guidelines regarding the COVID-19 infection have been added to the official guidance and take the place of the interim rules that were released earlier this year. Some codes are new, and some have been removed. Be sure you’re using current information to ensure claims are processed accurately and your patients aren’t accumulating balances they are not required to pay.

Will the new coding guidelines result in downcoding?

Because of changes in the way urgent care visits will be coded, there is a lot of speculation that urgent care clinics will lose revenue once these guidelines are in effect. Even though new coding guidelines may result in a lower-level E/M in 2021, it is impossible to predict whether all E/M encounters will be downcoded next year. An audit of your current E/Ms using 2021 guidelines with a large sample can help you predict your future revenue stream.

In addition to a self-audit, it’s important to be sure billers are clear on the new codes to avoid delays in reimbursement once new guidelines are in place.

Prepare for Telehealth Claims Audits

Medicare audits are back in full swing so it’s time to review your compliance controls—specifically when it comes to telehealth. These popular service options will likely be a primary claims review target in the months ahead. Now that audits of telehealth claims have restarted, remember that the reviewers are looking for a wide range of issues. Although you may be confident that you don’t have “intent” to improperly report these claims, an auditor may feel differently.

Although telehealth was in play prior to the pandemic, the United States’ volume of telemedicine services measured in the tens of thousands. But since the introduction of COVID, that number has risen into the tens of millions. Urgent care clinics offering telehealth services can expect regulatory agencies to investigate whether claims are being reported and documented properly. According to studies, telehealth claims have a history of inaccurate documentation.

According to industry experts, auditors are expected to factor COVID-19 hardships into their final decisions. But that doesn’t mean providers should expect a less that stringent review. Every indicator suggests that telehealth reviews will be ramping up instead of down—even though the public health emergency (PHE) has been extended. Auditors plan to stick to billing and coding guidelines and align with federal mandates. Due to the expansion and current proposals, practices should be especially ready for reviews of their telehealth claims.

Interested in more?

Check out Experity’s Coding Central for more billing tips, revenue cycle best practices, and urgent care coding updates.