As you may be aware, increasing numbers of insurance payors are considering “unspecified” ICD-10 codes as “non-covered” charges. Unspecified codes are meant to be used when the medical record information is insufficient to apply a more specific option. The CMS coding guidelines for 2023 suggest that unspecified codes be used sparingly. With the amount of rejections EMB has seen, our recommendation is to not use them at all, when possible.

Rejections from unspecified diagnosis codes impact an organization’s cash flow. A denial delay can mean another doctor gets paid instead of you, because they submitted a “correct” claim first. Corrections can take months to process and often require additional documentation. The need for a correction process can significantly delay or entirely halt reimbursement.

Suggested best practice has always been a thoroughness with medical records and specific diagnosing. We recommend using specified diagnosis codes at every opportunity to help maximize your reimbursement potential and mitigate risks to cash flow. Please reach out to EMB if you have questions or concerns regarding this.

At the start of 2023, several evaluation and management (E/M) CPT/HCPCS codes were removed from use, affecting how you report your encounters to EMB. Under the current system, selecting the appropriate level of an E/M service is based on medical decision-making or total time for services performed per date of service. If time is the determinant, the medical record must clearly document a start time, an end time, and the total time spent with the patient.

EMB can answer any questions about the codes you commonly utilize.

The Department of Health and Human Services (HHS) has announced the plan for the federal COVID PHE to expire at end of day on May 11, 2023. HHS has stated that most current Medicare telehealth flexibilities will remain through December 2024 due to the Consolidated Appropriations Act that passed in December.

Despite these extensions for Medicare, commercial insurance is often vastly different from one patient to the next. This may mean no coverage for audio-only telehealth specifically or potentially no virtual health coverage at all. Therefore, EMB recommends that providers have patients confirm telehealth eligibility with their own plans. It is advisable to have patients sign a disclosure indicating that they understand they may be billed for virtual care, if telehealth is not one of their designated benefits.

Behavioral health continues to be the most commonly covered telehealth service with commercial plans and at in-person rates.