Webinar #3 - All Other Questions, Comments, and Answers!

Chip & Paulie's Webinars
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Questions answered during the webinar:

1 Can this vaccine table be shared? ie our office website, fb/ notice? We're really trying to keep pts coming for "baby shots" Be my guest!
2 Why not use face time? It’s easy Because it's insecure. Because there are tools that will help you do things like collect forms, collect money, manage a waiting room, etc. And Facebook tracks you.
3 Are people using 99442 or 99213 with 95 modifier Both. It depends on the service provided (telemedicine or telephone) and payer policy.
4 Is G2012 patient initiated only? (heard on webinar at lunch) or can we use it when Provider initiates call outbound to check on patients I.e. ADHD/Depression? I believe that the G2012 has to be patient initiated but I'm not a coder!
5 '@chip hart - would it be better to compare decrease to same time last year given that late March and early April is so slow anyway? I don't like comparing to last year or the year before because any give week is at a different point in the typical viral wave from year to year. There can be a 20% natural swing, believe it or not.
6 Chip, does the sick include televisists? Are clinics seeing in office sick visits? I have clients who are still at 90%+ of their niormal in-office capacity. Not a lot, but for real.
7 United/Cigna/Humana state they will not pay for WCC on telehealth, what can we do to fight this on a AAP or PMI side? Is this national or just Colorado? I'm going to address this later to an extent. It's national.
8 In the State of Maryland the Governor has ordered that visits can take place during the pandemic by telehealth or any other audible device including a regular telephone. My providers are not currently billing for their telephone calls due to the previous rule that an office visit can not occur within 7 days for the same problem. Given the fact that the public has been ordered to stay home and we have been advised to conduct all possible visits including well care remotely via telephone or telehealth, does that rule not apply currently? Should we then bill all telephone encounters as regular e&m codes and not use the traditional telephone codes? If your payers have, like Medicare, issued an edict that permits you to bill 9921x instead of phone codes for phone care - I'll go out on a limb and say, you'd be crazy not to! It pays much better and you don't have the "count back 7 days, look forward 1 day" limit.
9 Shouldn’t we wait until AFTER the surge to push to get these vaccines caught up - maybe run some vaccine clinics? It's going to be incredibly local - the situation of your practice, how backed up you are, what other practices are doing, etc. In other words...you might want to wait. But I bet youll want to return to a full schedule ASAP no matter what!
10 Are practices really being inundated with Telehealth visits? We get maybe 5/d It's quite variable depending on region.
11 If we use telephone with FaceTime when needed Which code to use Look on forum.pediatricsupport.com for a number of coding references - but I recommend strongly against using Facetime unless absolutely necessary. There are other, free but medically oriented tools.
12 Do all states require telehealth phone calls be done by MD,PA,NPs in order to charge. Medicare has approved RNs to take those calls as 99211s I believe, which is a game changer.
13 Can you charge after hours e/m with telemedicine e/m? Can you charge after hours e/m with telephone 99441-3 cpt? No. The definition of 99051 and 99050 includes the phrases "services provided in the office...."
14 Patients don’t suddenly want to pay a copay for telemedicine. They still call in and want care for free. Does anyone there actually practice medicine? Paulie and I have clients all over the country. I speak to dozens every day. The reaction patients have to telemedicine differs from practice to practice. Some LOVE it. Many love it. Dr. Berman is a practicing pediatrician and runs a practice in TN with her husband.
15 My biller was saying you can only bill when patient calls in to office not when MD calls to patient. Any validity to this? Phone and electronic visits (portal/email) must be PATIENT initiated. Video-based visits can be MD-initiated.
16 What is the best way to use this data to advocate for relief from pharma companies/vaccine suppliers? Share it directly with them and ask them what they are doing to help. Who is going to give the vaccinations (i.e., BUY THEM) if you go out of business?
17 Chip, these 90% clinics are in no Covid areas, or they have figured a way to bring in people? Some are in places with low-COVID. Some are just willing to stay open. I reserve judgement.
18 Do these tele night calls need to be on a video platform, or can they just be phone calls? They can be either, but phone calls are often not paid well or at all.
19 If we have all records on a new patient but not seen in the office, could our doctors do TeleHealth on that new patient if the patient is sick? This is going to be payer dependent - Medicare allows it (at least they have approved those codes) but the commercial plans make up their own rules.
20 does the 99211 phone call have to be an RN or can it be an MA? Unless your state scope of practice laws are different, it can be anyone who furnishes ancillary services in your practice.
21 We are on-call every night. Usually our NP’s take the calls. Are all these calls billable? YES!
22 Can we bill insurances for PPE used? You can bill 99070. Whether insurances pay anything for it is another question. Your Pediatric Council can assist you here.
23 Do these tele night calls need to be on a video platform, or can they just be phone calls? You can do them any way you want, but phone calls don't pay as much as video visits and are often covered poorly. I'd recommend turning as many of them into video calls as possible!
24 any reason to do video telehealth if just phone telehealth is reimbursed the same? You get another clinical and social layer...

Open questions:

29 are we switching from “monopoly” to “risk”?
30 Before I forget... we have received telemedicine payments from 4 different insurance companies. Not one is equivalent to an in office visit. All are between an office visit and a telemedicine visit, roughly 12-20 dollars less than an office visit
31 but i’m being told payor won’t pay if nurse does the telephone encounter. only paid if physician does.
32 California does not have a pediatric council
33 Can some one please post the link for that Verden document Chip was referring
34 can you charge a telemedicine visit or phone consult with weekend hours or after hours???
35 Check if your hospital can have their neonatologist round on newborns and then refer to your practice
36 does IL have a pediatric council? unfortunately, the IL AAP is never responsive to those of us practicing outside of Chicago
37 has anyone done, or know if, group televisits are able to be scheduled/billed? would love to do group q&a re coronavirus or even mommy groups or group anticipatory guidance around certain ages where parents want to delay the well check but still may be interested in advice..
38 I believe that you can NOT add the time that the nurse spoke with the parent/patient as time spent if you take over.
39 if you are not a Medicaid par provider you can’t see a patient that has Medicaid except for free, correct? . they can’t be self-pay, correct?
40 if your insurance pays for phone calls using E/M codes, then RNs can use 99211 and it can be billed. If they use 9944x codes, you can’t bill for RN calls.
41 Medicaid plans are also highly vested in keeping their HEDIS rates up. They need well visits and immunizations to continue for HEDIS purposes. Not consistent with what is going on with the increased use of telehealth...I haven't found anyone who can give an immunization via Telehealth yet...
42 Now that the CDC is likely to recommend all folks should be wearing masks, is there going to be a need to keep track of what PPE we had and when? What we decided to wear and when if we have made due with what we could get?
43 Our big question I'm hoping you can answer tonight: We have 4 offices. 2 are a fair bit bigger. The smaller offices are 35 minutes from the bigger ones. We have about 50% reduction in visits. At one point, would you recommend consolidating the smaller offices into the bigger ones? We have already reduced staff at those offices to one staff member per doctor with reception handling the phones for the smaller offices.
44 our health departments in IL are not seeing patients and therefore not vaccinating children with Medicaid or those uninsured.
45 So, I have found that doing my behavioral/mental health visits via telemedicine are shorter and really from a time perspective are at a 99213 and not a 214. Is everyone else seeing this also?
46 THE WINNING ARGUMENT is that the healthcare system needs Peds alive when a vaccine against COVID is invented because we are at the only ones who can give mass vaccines
47 What is the best way to advocate for relief from pharma companies? We have heard from Pfizer about extended payment windows but wondering if/when we will hear more from other pharma companies and if anyone has success stories for direct advocacy.
48 Why was the coding hotline with the AAP that you mentioned? And thank you, thank you for this.
49 Is now a good or bad time for CCOF? Good because need $ and people more likely to avoid paying... bad because of people’s stress and how “mean” this action will be perceived
50 How can some non-Medicaid plans like Highmark wave co-pays unilaterally?
51 what should medical practices do when they have numerous employeed physicians making more than $100,000/year (so they wont be fully covered by the loan) but there is not enough revenue to cover their salaries?
52 Dr. Berman, we are not getting paid for worried well ( mom calls, worry about Covid). Do you have an ICD which works?
53 How do we account the expected glitches in payment for telemedicine since many carriers don’t seem to have their act together yet to process these correctly?
54 can you touch on the reimbursement/charges for phone calls returned by our nurse.
55 We are following guidelines for “essential” visits which is 2 years and under that require vaccines. Are most other practices following these guidelines also or just seeing ANY well visits that are willing to come in?
56 Is now a good or bad time for CCOF? Good because need $ and people more likely to avoid paying... bad because of people’s stress and how “mean” this action will be perceived
57 If FaceTime not used since not needed what would u use
58 Could we get Kerin's email address?
59 What about 6 ft distance in medical offices? Hard to maintain? Can they claim its unsafe?
60 anthem is denying all of our A/R requests for reconsideration for improperly paid claims past 60 days of payment/processing.. is there any recourse?
61 We had an insurance company say they could not discuss a claim before covid because they are too busy - is that legal? Wait times are even more awful w many of them now also -
62 Chip, you said if Telehealth gets denied, resubmit. Won't they say its duplicate billing?
63 How about telemedicine for updating asthma diagnoses, watching their MDI techniques, checking compliance with meds, updating the severity of disease, doing an asthme control test and updating their asthma action plans?
2

I thought this was the most clever line of the evening (from Dr. James Weidman, to give credit) and expect to steal it.

3

Proper billing of both the phone and digital codes requires that the patient initiate the encounter. [IANAC - I am not a coder]

4

I think this was the most popular question we received the entire time!

Find their document here.

5

Correct! Although I don’t expect this rule to be changed, anything is possible.

6

This is the best opportunity pediatric practices will have to catch up with the all the chronic disease conditions so many of you can’t keep up with. Let’s look for silver linings.

7

aapcodinghotline@aap.org

Note that they must be SWAMPED right now.

8

This needs to be in every communication you have with your elected officials, payor reps, etc.

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Omnibus Q&A:

|30|Before I forget… we have received telemedicine payments from 4 different insurance companies. Not one is equivalent to an in office visit. All are between an office visit and a telemedicine visit, roughly 12-20 dollars less than an office visit|

Are your payers supposed to pay the same, or does your fee schedule permit them to pay differently? What do their policies on their website/provider manual say?

|31|but i’m being told payor won’t pay if nurse does the telephone encounter. only paid if physician does.|

I take the blame for not making this one crystal clear. At this time, only a few payers have relaxed their policies to pay regular E&M for telePHONE visits. If your payer permits this, you can use 99211 for nurse calls, just like you can use 99211 for in-office nurse assessments. Unfortunately, the vast majority of payers at this time have no mechanism to pay and report for nurse-only telephone calls. Even 98966-8 can’t be used in most states right now. Stay tuned.

|32|California does not have a pediatric council|

That is correct… I’ve never understood how the largest state couldn’t scrape together a handful of people to do this. If you’re interested, contact Sue Kressly or Lou Terranova at lterranova @ aap . org to get AAP support in starting one.

|34|can you charge a telemedicine visit or phone consult with weekend hours or after hours???|

99050/99051 have the phrase “services provided in the office,” so I assume that means no.

|36|does IL have a pediatric council? unfortunately, the IL AAP is never responsive to those of us practicing outside of Chicago|

Ask Lou (see answer #32)

|38|I believe that you can NOT add the time that the nurse spoke with the parent/patient as time spent if you take over.|

For any kind of time-based code, yes, this is generally true.

|39|if you are not a Medicaid par provider you can’t see a patient that has Medicaid except for free, correct? . they can’t be self-pay, correct?|

Most states permit you to see Medicaid patients as self pay if you are COMPLETELY non-par with your state’s Medicaid: You don’t have a Medicaid ID number, you have no contractual relationships with any of your state’s MCOs, and you never bill Medicaid.

|40|if your insurance pays for phone calls using E/M codes, then RNs can use 99211 and it can be billed. If they use 9944x codes, you can’t bill for RN calls.|

That is correct.

|42|Now that the CDC is likely to recommend all folks should be wearing masks, is there going to be a need to keep track of what PPE we had and when? What we decided to wear and when if we have made due with what we could get?|

Yes, this should be part of your office’s OSHA plan.

|43|Our big question I’m hoping you can answer tonight: We have 4 offices. 2 are a fair bit bigger. The smaller offices are 35 minutes from the bigger ones. We have about 50% reduction in visits. At one point, would you recommend consolidating the smaller offices into the bigger ones? We have already reduced staff at those offices to one staff member per doctor with reception handling the phones for the smaller offices.|

There may be a slight numerical advantage to consolidating your work into fewer locations, i.e. smaller utilities. Most of your expenses (mortgage/rent, people, supplies) are going to be the same whether you use 2 offices or 4 offices. In terms of social distancing and reducing risk, it seems better to have four smaller teams than two larger teams - I’d rather lose 25% of my staff for 2 weeks than 50% in the case of an exposure.

|45|So, I have found that doing my behavioral/mental health visits via telemedicine are shorter and really from a time perspective are at a 99213 and not a 214. Is everyone else seeing this also?|

Sounds like a good question for the Data Nerds in an upcoming show :slight_smile:

|47|What is the best way to advocate for relief from pharma companies? We have heard from Pfizer about extended payment windows but wondering if/when we will hear more from other pharma companies and if anyone has success stories for direct advocacy.|

In addition to AAP taking up this cause, some chapters are working on this. I haven’t yet heard anyone posit the strategy of “Just let the darn vials expire, then turn them in for a refund.”

|48|Why was the coding hotline with the AAP that you mentioned? And thank you, thank you for this.|

aapcodinghotline@aap.org

|49|Is now a good or bad time for CCOF? Good because need $ and people more likely to avoid paying… bad because of people’s stress and how “mean” this action will be perceived|

More good than bad. It’s all in how you implement it, what words you choose, etc. People shouldn’t think expecting to be paid at the time of service/when the EOB is adjudicated is “mean.” When you check into a hotel or rent a car, the first thing they ask you for is a credit card. I don’t see why medical practice is so different.

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|50|How can some non-Medicaid plans like Highmark wave co-pays unilaterally?|

It depends what you mean by waive copays. If you mean “remove cost share,” then this is great - less work for you, less out of pocket for the patient, you still get your full fee without having to chase anyone with statements. If you mean “unilaterally reduce what you’re paid for a contractually agreed-on CPT code,” then yes, the usual “send information to your PAAC/Pediatric Council” advice would apply.

|51|what should medical practices do when they have numerous employeed physicians making more than $100,000/year (so they wont be fully covered by the loan) but there is not enough revenue to cover their salaries?|

No easy option. I lay the possibilities out here: Webinar #1 - Distilled Chat Comments

|52|Dr. Berman, we are not getting paid for worried well ( mom calls, worry about Covid). Do you have an ICD which works?|

I’ve never gotten paid for using the worried well diagnosis even for office visits. However, mom usually reports some minor symptom that you can use for coding purposes. You can send a redacted transcript of what you documented to the AAP Coding Hotline (see #48) and they’ll give you ideas on what codes you can use.

|53|How do we account the expected glitches in payment for telemedicine since many carriers don’t seem to have their act together yet to process these correctly?|

Assuming it’s not an ERISA plan: Take them to task with your state insurance commissioner using your state’s prompt payment law.

|54|can you touch on the reimbursement/charges for phone calls returned by our nurse.|

See #31.

|55|We are following guidelines for “essential” visits which is 2 years and under that require vaccines. Are most other practices following these guidelines also or just seeing ANY well visits that are willing to come in?|

It’s all over the map. A plurality of practices are doing under 2 AND now, trying to keep whoever will come in.

|56|Is now a good or bad time for CCOF? Good because need $ and people more likely to avoid paying… bad because of people’s stress and how “mean” this action will be perceived|

See #49.

|59|What about 6 ft distance in medical offices? Hard to maintain? Can they claim its unsafe?|

I presume you’re asking, “Can my employees file an OSHA (or similar) claim against me because they’re not separated at all times from other folks by 6 feet minimum?” There’s a lot of other questions here. Are these billers who could be answering the phone from home, but you’ve refused to let them telework, or are these two nurses wearing PPE who put their heads close to each other to restrain a kid who needs vaccines? Are you still requiring weekly staff meetings where your entire staff squeezes next to each other in the break room?

|60|anthem is denying all of our A/R requests for reconsideration for improperly paid claims past 60 days of payment/processing… is there any recourse?|

What do your contracts and state insurance law say? Have you brought this to your state insurance commissioner, PAAC or Pediatric Council?

|61|We had an insurance company say they could not discuss a claim before covid because they are too busy - is that legal? Wait times are even more awful w many of them now also -|

Nope, especially since YOUR clock is ticking in terms of contesting it. You can send that to your state insurance commissioner.

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I would strongly consider turning one or more of the locations into WELL VISIT ONLY locations and using the others for sick. I realize you have some spread of locations but…it’s not like traffic is heavy right now. With 4 locations, you might call one location the VACCINE location, another the non-vaccine location for well visits, and see sick at the other two. If one of the well visit spots gets compromised, you have one left to roll to.

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I would offer CCoF but not be too strict on it…at a minimium, it would be a c onvience for patients…