From continual updates to ICD-10, CPT and lab codes and special modifiers to telehealth expansion, the healthcare industry has had to deal with dramatic changes since the COVID-19 outbreak. Medical coding service providers need to continually implement novel strategies to help organizations manage their revenue cycle, including documenting and billing for new services to meet new reimbursement policies.
The following are the major healthcare revenue cycle management (RCM) challenges presented by the coronavirus pandemic:
- COVID-19 Billing and Coding: As clinicians focused their efforts on diagnosing and treating patients with SARS-CoV-2 symptoms andinfection, they had to deal with new codes and billing guidelines to report their services.
- New ICD-10 Codes: Starting with the ICD 10 emergency code 1 – 2019-nCoV acute respiratory disease, effective April 1, 2020, the Centers for Disease Control and Prevention (CDC) required providers to exposure to COVID-19 using code Z03.818 – Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure, but ruled out after evaluation). Effective January 1, 2021, there are six new diagnosis codes for COVID-19. U07.1 should be the primary diagnosis, followed by appropriate codes for associated manifestations, for e.g., J12.82 (Pneumonia due to coronavirus disease 2019). Appropriate codes have to be used to report signs and symptoms, e.g., R05 (cough). There are separate COVID-19 diagnostic coding guidelines for pregnant patients. CMS has also introduced 21 new ICD-10-PCS codes for the vaccination and treatment of coronavirus.
- New CPT Codes: There are several CPT and HCPCS codes specific to COVID-19 testing. CPT codes have been introduced to report each coronavirus vaccine as well as administration codes for each vaccine. CPT code 87635 (effective March 13, 2020) was established to report infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique. CPT code 86413 has been introduced to report quantitative antibody detection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Code 99072 was established to report additional practice expenses incurred during a Public Health Emergency (PHE), including supplies and additional clinical staff time.
The major challenge is that billing processes for state Medicaid programs and private payers vary. Billers and coders need to communicate with payers for guidelines on how to submit claims for the COVID-19 vaccine and administration.
- Reporting Telemedicine Services: As coronavirus spread, telemedicine emerged as an important tool to better care for people who have contracted the virus. The Centers for Medicare & Medicaid Services (CMS) issued multiple waivers providing flexibility with regards to geographic location, type of health site, etc., and granted payment parity between telehealth and in-person clinical care for Medicare. Private insurance companies also supported the transition to telehealth options during the pandemic. However, providers had to deal with interstate licensure challenges and other regulatory issues that may vary by state. Moreover, even as payers supported the transition to virtual care, as Revenue Cycle Intelligence notes, coders and billers had to identify how to document and bill for the new services amid frequent policy and regulation changes.
- Rising Claim Denials: Under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, private health plans are required to cover COVID-19-related diagnostics and care (“qualifying coronavirus preventive service”) without co-pays, deductibles, and claim denials. However, medical billing provisions in the Act have led to an increase in mispayments and claims denials. Recent surveys also show that the introduction of new codes for COVID-19-related services, changing payer rules, including for telehealth, and problems tracking varying payer requirements have complicated claim processing (www.hfma.org). According to the Change Healthcare 2020 Revenue Cycle Denials Index, medical claim denials have risen 11% nationwide, since the outbreak of the COVID-19 pandemic.
All of these challenges show just how important it is for healthcare providers to have a reliable medical billing and coding partner. With annual updates to ICD-10 and CPT codes and payer policies, the support of certified and experienced coders and billing specialists is crucial for efficient RCM. Reputable providers of outsourced billing services have teams that stay up to date on changes in coding sets, industry developments, and regulations to help clinicians ensure accurate documentation and prevent denials. They also have the expertise to determine the root causes of denials, take action to correct them, and help providers get paid appropriately for services rendered.