Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare audio only telehealth services billed on dates of service from March 6, 2020 through June 1, 2021. Below are the review results:

Background

In response to the declaration of the COVID-19 outbreak as a Public Health Emergency (PHE), the Secretary authorized waivers and modifications under Section 1135 of the Social Security Act (the Act). Additional flexibilities were granted during the PHE via rulemaking. These waivers and flexibilities help prevent potential gaps in access to care for beneficiaries impacted by the emergency. These flexibilities and waivers can be found at Waivers & flexibilities for health care providers .

Title XVIII of the Social Security Act (SSA) § 1834(m) indicates the Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician or a practitioner to an eligible telehealth individual providing the telehealth service is not at the same location as the beneficiary. Under the waivers and flexibilities established during the PHE, CMS expanded the use of audio only telehealth codes to a range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, who will be able to offer telehealth to their patients. In addition, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country, including in patient’s places of residence. CMS further changed the payment status of CPT codes 98966-98968 and 99441-99443 from categorically noncovered services, to allowable services.

Reason for Review

The SMRC was tasked with performing claim review on a sample of audio only telehealth services claims. The SMRC completed medical review on a sample of claims with dates of service from March 6, 2020 to June 1, 2021. Applicable waivers and flexibilities established during the PHE were utilized during claim review activities.

Common Reasons for Denial

• No Response to the Documentation Request
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• The documentation does not support the service was performed as billed.
  • The billed service is adjusted to pay for the service provided. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23

References/Resources

Title XI of the Social Security Act (SSA)

• § 1135 Authority to waive requirements during national emergencies

Title XVIII of the Social Security Act (SSA)

• § 1815(a) Providers must furnish information
• § 1833(e) Payment of Benefits
• § 1834(m) Payment for Telehealth Services
• § 1842(p)(4) Provisions Relating to the Administration of Part B
• § 1861. Part E – Miscellaneous Provision.
• § 1862 Exclusion from Coverage and Medicare as a Secondary Payer
• § 1879 (a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• § 1893 (f)(7)(A)(B) (i-iv) Medicare Integrity Program

Articles

• CMS 1744-IFC. Medicare and Medicaid Programs, Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
• Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). Telehealth Services During Certain Emergency Periods
• Public Health Service Act, 2021, Section 319(e) Telehealth Enhancements for Emergency Response
• Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments

Title 42 of the Code of Federal Regulations (CFR)

• 400.200 General Definitions
• 405.2464(e) Payment Rate
• 410.20 Physician Services
• 410.69 Services of a Certified Registered Nurse Anesthetist or an Anesthesiologist’s Assistant: Basic Rule and Definitions
• 410.71 Clinical Psychologist Services and Services and Supplies Incident to Clinical Psychologist Services
• 410.73 Clinical Social Worker Services
• 410.74 Physician Assistants’ Services
• 410.75 Nurse Practitioners’ Services
• 410.76 Clinical Nurse Specialists’ Services
• 410.77 Certified Nurse-Midwives’ Services: Qualifications and Conditions
• 410.78 Telehealth Services
• 410.134.Provider Qualifications
• 411 Exclusions from Medicare and Limitations on Medicare Payment
• 411.15 Particular Services Excluded from Coverage
• 413.65 Requirements for a determination that a Facility or an Organization has Provider-Based Status
• 424.5 Basic Conditions
• 482.24 Condition of Participation: Medical Record Services

Internet-Only Manual (IOM) Medicare Benefit Policy Manual Publication 100-02

• Chapter (Ch.) 15, § 270 Telehealth Services
• Ch. 16 General Exclusions from Coverage

IOM, Medicare Claims Processing Manual, Publication 100-04

• Ch. 12, § 20.3. Bundled Services/Supplies
• Ch. 12, § 30.6 Evaluation and Management Service Codes-General (Codes 99201-99499)
• Ch. 12, § 190 Medicare Payment for Telehealth Services
• Ch. 18 Preventive and Screening Services
• Ch. 23 Fee Schedule. Administration and Coding Requirements
• Ch. 30, § 30.2 Healthcare Provider or Supplier Knowledge and Liability
• Ch. 30, § 50 Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)

IOM, Medicare Program Integrity Manual, Publication 100-08

• Ch. 3, § 3.2.3.8 No response of Insufficient Response to Additional Documentation Requests
• Ch. 3, § 3.3.2.4 Signature Requirements
• Ch. 3, § 3.6.2.1 Coverage Determinations
• Ch. 3, § 3.6.2.2 Reasonable and Necessary Criteria
• Ch. 3, § 3.6.2.3 Limitation of Liability Determinations
• Ch. 3, § 3.6.2.4 Coding Determinations
• Ch. 3, § 3.6.2.5 Denial Types
• Ch. 13, § 13.5.4 Reasonable and Necessary Provisions in LCDs

Other

• American Medical Association, Current Procedural Terminology (CPT) Manual, Professional Edition (2020)
• Medicare Learning Network (MLN) 2020-11-12-MLNC, COVID 19: Non-Physician Practitioner Billing Audio Services
• National Correct Coding Initiative Coding Policy Manual for Medicare Services

Last Updated Jun 29, 2022