Interview Questions for Telehealth Billing and Coding

Both CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) codes are used for billing medical services, including telehealth. However, they serve different purposes. CPT codes are primarily used for physician services and are maintained by the American Medical Association (AMA). They are five-digit numeric codes that describe the specific medical procedure or service provided. HCPCS codes are a broader system that includes CPT codes, but also expands to include supplies, products, and services not typically covered by CPT. In the telehealth realm, CPT codes describe the type of telehealth visit (e.g., a virtual office visit), while HCPCS codes might be used for billing specific devices or supplies used during the telehealth encounter, such as remote patient monitoring equipment.

Example: A telehealth visit using video conferencing might be billed using a CPT code specific to telehealth office visits, while any additional equipment used during the visit (like a blood pressure monitor) may be billed using a relevant HCPCS code. This distinction ensures accurate and comprehensive reimbursement.

Submitting telehealth claims to Medicare requires careful attention to detail and adherence to specific guidelines. First, ensure the patient is eligible for Medicare telehealth services and that the service meets Medicare’s criteria for telehealth coverage. Then, you’ll need to use the appropriate CPT and/or HCPCS codes, including modifiers to indicate that the service was provided via telehealth (e.g., modifier 95). The claim must include information such as the place of service (POS), typically designated as a telehealth originating site, and accurate patient demographic information. Finally, all claims must be submitted electronically through a Medicare-approved billing system.

Step-by-step process:

• Verify eligibility: Confirm the patient’s Medicare coverage and telehealth eligibility.
• Accurate coding: Use the correct CPT and HCPCS codes and modifiers.
• Place of service: Clearly indicate the telehealth originating site (POS code).
• Electronic submission: Submit the claim electronically through a Medicare-approved clearinghouse.
• Follow-up: Monitor claim status and address denials promptly.

Medicare has specific requirements for the originating site and the types of telehealth services covered. Failure to meet these requirements can lead to claim denials.

Common telehealth billing and coding compliance issues stem from a lack of understanding of the specific regulations and guidelines. Some frequent problems include:

• Incorrect coding: Using the wrong CPT or HCPCS code for the telehealth service provided.
• Missing modifiers: Failing to include necessary modifiers to indicate that the service was provided via telehealth.
• Incorrect place of service: Incorrectly reporting the place of service, which impacts reimbursement.
• Lack of documentation: Inadequate medical record documentation to support the billed services.
• Improper patient consent: Not obtaining proper informed consent from the patient for telehealth services.
• Violation of HIPAA regulations: Non-compliance with HIPAA rules regarding the security and privacy of patient health information.

These issues can result in claim denials, audits, and potential financial penalties. Staying current with the ever-evolving regulations and guidelines is crucial for avoiding these problems.

Handling telehealth billing denials requires a systematic approach. First, you need to understand the reason for denial by carefully reviewing the Explanation of Benefits (EOB) or remittance advice. Common reasons include incorrect coding, missing information, or issues with patient eligibility. Next, investigate the issue and gather supporting documentation, such as the patient’s medical record, to verify the claim’s accuracy. If the denial was due to an error on your part (e.g., incorrect coding), correct the issue and resubmit the claim with the necessary corrections. If the denial is due to a payer policy issue, you may need to appeal the denial, following the payer’s specific appeal process.

Example: A claim is denied due to a missing modifier. By reviewing the EOB and adding the correct modifier (e.g., 95), the claim can be resubmitted for payment.

Payer-specific rules significantly impact telehealth billing. Different payers (Medicare, Medicaid, private insurance) have their own eligibility criteria, covered services, reimbursement rates, and documentation requirements for telehealth. For example, Medicare may require a specific type of technology for a virtual visit, whereas a private payer might not have such a restriction. Another payer might have a specific list of diagnoses that qualify for telehealth reimbursement. It’s crucial to be aware of these variations as using the wrong codes or failing to adhere to specific payer rules will lead to claim denials. Maintaining an up-to-date understanding of each payer’s policies is essential for successful telehealth billing.

Example: A telehealth visit that is covered by Medicare may not be covered by a specific private insurer due to their different telehealth policies and benefit structures.

A clean telehealth claim is one that is accurately and completely submitted, free from errors that cause delays or denials. Key elements include:

• Accurate patient information: Correct name, date of birth, insurance information, etc.
• Appropriate CPT/HCPCS codes: Use the correct codes for the services provided, including telehealth modifiers (e.g., 95).
• Correct place of service (POS): Accurate identification of the originating site for the telehealth visit.
• Complete documentation: Thorough medical record documentation supporting the services billed.
• Proper billing format: Submission of the claim through the correct electronic format.
• Compliance with payer rules: Adherence to specific payer policies regarding telehealth services.

Submitting clean claims reduces administrative burden, improves cash flow, and maintains compliance with payer guidelines.

Ensuring accurate coding for various telehealth services requires a thorough understanding of CPT and HCPCS codes, as well as payer-specific guidelines. Always refer to the most up-to-date coding manuals and payer policies. For each telehealth service provided, identify the specific CPT or HCPCS code that accurately reflects the service, taking into account the type of visit (e.g., office visit, psychotherapy), the modality used (e.g., audio-only, video), and any additional procedures or services performed. When using electronic health record (EHR) systems, make sure your EHR is properly configured to reflect telehealth specific codes and modifiers. If unsure about the appropriate code, consult with a qualified coding specialist or refer to authoritative coding resources.

Example: A synchronous telehealth visit with a patient using video conferencing would require a different code than an asynchronous telehealth visit where the patient provides data through a remote patient monitoring device.

Telehealth platforms vary widely, each impacting billing differently. The platform’s features determine the level of integration with electronic health records (EHRs) and billing systems, significantly impacting efficiency and accuracy. For example, some platforms offer direct integration with major billing systems, automating claim submission and payment posting. Others may require manual data entry, increasing the risk of errors and delays.

• Dedicated Telehealth Platforms (e.g., Teladoc, MDLIVE): These platforms often have built-in billing capabilities, sometimes handling billing directly or providing robust interfaces to integrate with your billing system. Billing implications vary based on their contracts and pricing models—some charge per visit, while others use subscription models. Careful review of their contracts is crucial.
• Video Conferencing Platforms (e.g., Zoom, Skype): While widely used, these lack built-in medical billing features. Integrating these requires using separate billing software and meticulously documenting services rendered. This manual process increases the likelihood of errors and delayed payments.
• EHR-Integrated Platforms: Many EHR systems now offer telehealth functionalities. These are often the most seamless for billing because patient information and visit details are automatically recorded. However, the billing integration specifics depend heavily on the EHR vendor and its capabilities.

In all cases, appropriate CPT and HCPCS codes must be applied accurately to ensure correct reimbursement. The platform’s ability to generate compliant documentation is also crucial.

I have extensive experience using several telehealth-specific billing software packages, including Kareo, DrChrono, and Practice Fusion. My experience ranges from initial setup and configuration to day-to-day operation and troubleshooting. I’m proficient in managing patient demographics, scheduling appointments, generating claims, posting payments, and running reports. For example, with Kareo, I successfully implemented a custom reporting system to track key performance indicators (KPIs) specific to our telehealth practice, significantly improving our revenue cycle management. I also have experience integrating these systems with various telehealth platforms, ensuring seamless data flow between the platforms and the billing software. A key advantage of dedicated telehealth billing software is their pre-built templates and functionalities optimized for telehealth-specific billing requirements—ensuring compliance with payer regulations.

Staying current with telehealth billing regulations is crucial. My approach involves a multi-pronged strategy:

• Subscription to professional journals and newsletters: I subscribe to publications like the American Medical Association (AMA) and Medical Group Management Association (MGMA) publications that provide updates on regulatory changes.
• Participation in webinars and conferences: Regularly attending industry events provides insights into current trends and best practices in telehealth billing and coding.
• Monitoring government websites: I actively monitor the websites of the Centers for Medicare & Medicaid Services (CMS) and other relevant regulatory bodies for announcements regarding billing rule changes.
• Networking with colleagues: Engaging with colleagues through professional organizations and online forums facilitates the exchange of information and experiences related to billing challenges.

This multifaceted approach ensures that I’m always aware of and prepared for any legislative updates.

Verifying patient insurance eligibility for telehealth visits is similar to in-person visits but requires attention to telehealth-specific coverage details. I typically use a combination of methods:

• Online Eligibility Verification Systems: Most payers have online portals that provide real-time eligibility information. I enter the patient’s demographic and insurance information to verify coverage, benefits, and any telehealth-specific limitations or requirements.
• Payer Direct Contact: If online verification is inconclusive, I contact the payer directly to clarify coverage details, focusing on whether telehealth visits are covered under the patient’s plan, any pre-authorization requirements, and the reimbursement rates.
• Patient Provided Information: While relying solely on patient-provided information is risky, I review the information they provide and cross-reference it with the payer’s online portals or direct inquiries to ensure accuracy.

Detailed documentation of the verification process, including date, method, and the results, is crucial for audit purposes and to prevent disputes down the line.

Discrepancies between patient statements and insurance payments in telehealth are often due to coding errors, incorrect patient information, or issues with payer adjudication. My approach involves a systematic investigation:

1. Review the claim: I begin by carefully reviewing the original claim, verifying the accuracy of the diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), and modifiers.
2. Contact the payer: I contact the payer directly to inquire about the reason for the discrepancy. I provide them with the necessary supporting documentation, such as the claim details and the patient’s insurance information.
3. Analyze the Explanation of Benefits (EOB): I thoroughly analyze the EOB to understand the reason for the payment difference and identify any areas requiring correction. This might indicate issues with pre-authorization, coding errors, or missing documentation.
4. Appeal if necessary: If the discrepancy cannot be resolved through initial contact, I prepare and file an appeal with the payer, providing clear and compelling evidence to support our claim for the full payment.

Each step is meticulously documented for tracking and auditing purposes, ensuring transparency and accountability.

Tracking key performance indicators (KPIs) is vital for optimizing telehealth billing and revenue cycle management. I track:

• Claims submitted vs. claims paid: This ratio indicates the efficiency of our billing process.
• Days in accounts receivable (A/R): This metric highlights how quickly we’re collecting payments, allowing identification of bottlenecks.
• Rejection rate: Tracking claim rejection rates helps identify areas for process improvement and coding accuracy.
• Average reimbursement per visit: Monitoring this provides insights into our pricing strategy and contract negotiations.
• Patient satisfaction with billing: Gathering feedback helps address issues promptly and enhance the patient experience.

Regularly analyzing these KPIs allows for proactive adjustments to our strategies, ensuring consistent and efficient billing practices.

Managing outstanding accounts receivable (A/R) in telehealth requires a proactive and multi-step approach.

1. Regular follow-up: I establish a system for regularly contacting patients and payers regarding overdue payments.
2. Automated reminders: Implementing automated email or text message reminders reduces manual effort and improves collection rates.
3. Patient communication: I use clear and empathetic communication to understand the reason for delayed payments and work collaboratively with patients to establish a payment plan.
4. Third-party collection agencies: For persistent overdue accounts, I engage third-party collection agencies as a last resort, but only after exhausting all other avenues. This involves careful selection of agencies that comply with all relevant regulations and ethical guidelines.
5. Regular A/R reports: I generate and review A/R reports regularly to identify trends and potential issues, allowing for early intervention.

The goal is to maintain a healthy A/R balance while ensuring positive patient relationships and compliance with all regulations.

HIPAA (Health Insurance Portability and Accountability Act) regulations are paramount in telehealth, extending all existing privacy and security rules to virtual care. This means maintaining patient confidentiality during virtual consultations, securing electronic health records (EHRs) used in telehealth, and ensuring the secure transmission of protected health information (PHI) during virtual sessions. For example, using end-to-end encrypted video conferencing platforms is crucial. My understanding of HIPAA extends to the specific requirements for telehealth, including the appropriate use of Business Associate Agreements (BAAs) with telehealth vendors to ensure they comply with HIPAA’s security and privacy rules. I’m familiar with breach notification procedures in case of any HIPAA violations, whether intentional or accidental, impacting patient data exchanged during telehealth encounters. I regularly stay updated on HIPAA updates and compliance measures to ensure continued adherence to these critical regulations.

My experience with auditing telehealth claims involves a rigorous process to ensure accurate coding, proper documentation, and compliance with payer regulations. I meticulously review claim data, comparing it against the corresponding medical records to verify the medical necessity of services provided and ensure that the codes used accurately reflect the services rendered. I also check for adherence to payer specific guidelines related to telehealth services, such as location requirements and the use of telehealth modifiers. This involves cross-referencing claims with supporting documentation such as progress notes, encounter forms, and patient demographics. An example of a common issue I find is inconsistencies between the documentation and the billing codes, which can lead to claim denials. I focus on identifying patterns of errors to implement corrective action, preventing future claim denials and improving revenue cycle management for telehealth services.

I have extensive experience with various EHR systems, including Epic, Cerner, and Meditech, and their integration with telehealth platforms. A smooth integration is crucial for efficient telehealth billing. This means ensuring that patient demographics, encounter details, and diagnostic information seamlessly transfer from the telehealth platform to the EHR. This reduces manual data entry, decreasing the likelihood of errors and improving billing accuracy. For example, I’ve worked on projects where we integrated telehealth platforms with our EHR system to automatically generate and submit claims, significantly reducing the administrative burden. I am also familiar with APIs and other technical aspects of EHR-telehealth integration, which allows me to troubleshoot technical issues that may arise and ensure optimal system performance.

Handling patient billing inquiries for telehealth services requires empathy, patience, and a thorough understanding of the billing process. I begin by actively listening to the patient’s concerns and gathering all relevant information. This might involve reviewing their account statements, claims, and medical records. Then, I clearly and concisely explain the charges, outlining the services rendered and any applicable codes. If there’s an error or discrepancy, I initiate a systematic investigation, following the appropriate procedures for claim corrections or appeals. For example, if a patient questions a charge for a telehealth visit, I would verify the date, time, and the type of service provided, cross-referencing it with the patient’s medical record and the billing information. I always ensure the patient leaves the conversation with a clear understanding of their bill and the next steps.

My experience encompasses various telehealth reimbursement models, including fee-for-service, capitation, and value-based care. Fee-for-service involves billing for each service rendered, while capitation is a per-patient payment model. Value-based care focuses on quality outcomes rather than the volume of services. Understanding these models is critical for accurate billing and reimbursement. For instance, under fee-for-service, I’d ensure accurate coding and documentation to support the claims. In a capitation model, I would focus on managing patient health proactively, aiming to minimize the cost of care while achieving positive health outcomes. For value-based models, data analytics and performance metrics become critical for measuring and demonstrating the effectiveness of telehealth interventions.

Identifying and preventing fraudulent activities in telehealth billing is crucial. This requires a multi-faceted approach. We start with implementing strong internal controls, including regular audits and monitoring of claims data for unusual patterns or outliers. This includes reviewing claims for medically unnecessary services, upcoding (using higher-level codes than justified), and duplicate billing. Furthermore, we implement strong authentication protocols to prevent unauthorized access to patient data and the billing system. Employee training is essential, ensuring everyone understands the compliance policies and procedures, and the potential consequences of fraudulent activity. We also actively monitor for unusual billing patterns, for example, an unusually high number of claims from a single provider or location. When suspicious activity is detected, a thorough investigation is launched.

Telehealth modifiers are appended to CPT (Current Procedural Terminology) codes to provide additional information about the type of service provided and the place of service. They’re crucial for correct reimbursement. For example, the modifier GQ indicates a synchronous telehealth service, while 95 indicates that the service was provided via asynchronous telehealth. These modifiers help payers distinguish telehealth services from in-person services and ensure appropriate payment. Understanding and correctly applying these modifiers is vital for accurate claim processing and preventing denials. Incorrectly applying modifiers can lead to claim denials or delays in payment. I have in-depth knowledge of all relevant telehealth modifiers and ensure their accurate application on all claims based on the specific telehealth service delivered.

My experience spans several telehealth billing systems, from large-scale enterprise solutions like Kareo and Practice Fusion to smaller, more specialized platforms. I’ve worked extensively with systems that integrate with electronic health records (EHRs), allowing for seamless claim submission and patient data management. For example, with Kareo, I’ve mastered configuring the system to accurately reflect telehealth-specific CPT codes and modifiers, ensuring proper reimbursement. In contrast, my experience with Practice Fusion involved troubleshooting integration issues with telehealth platforms like Zoom and Doximity, optimizing the workflow for efficient billing. Each system presents unique challenges and opportunities; my expertise lies in adapting my approach to leverage the strengths of each platform while mitigating their weaknesses.

• Kareo: Proficient in configuring CPT codes, modifiers (e.g., -95 for synchronous telehealth), and payer-specific requirements.
• Practice Fusion: Experienced in troubleshooting integration issues with various telehealth platforms and optimizing workflow for efficient claim submission.
• Athenahealth: Familiar with their robust reporting and analytics capabilities, allowing for detailed performance monitoring.

Reporting and analysis are critical to ensuring the financial health of any telehealth practice. My experience involves using telehealth billing systems to generate reports on key metrics such as revenue cycle efficiency, claim denial rates, and payer-specific reimbursement trends. I’m adept at using data visualization tools to identify areas for improvement. For instance, I once used a Practice Fusion report showing a high denial rate for a specific CPT code with a particular payer to investigate the issue. This revealed an incorrect modifier being applied; after correction, the denial rate for that code dropped significantly. I regularly monitor key performance indicators (KPIs) to proactively identify and address potential billing bottlenecks. This includes analyzing claim submission times, average reimbursement rates, and outstanding balances.

Complex telehealth billing scenarios often involve issues such as incorrect coding, missing documentation, or payer-specific rules. My approach involves a systematic investigation. First, I meticulously review the patient’s chart, ensuring that all necessary documentation supporting the services provided is present. Second, I verify the accuracy of the CPT codes and modifiers used, referencing the most current guidelines from the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS). Third, I analyze the payer’s specific rules for telehealth reimbursement, including any geographical restrictions or service limitations. For example, a recent case involved a patient who received a combination of in-person and telehealth services. Accurate billing required careful separation of the codes and modifiers, ensuring compliance with payer guidelines. Finally, if a denial occurs, I initiate an appeal process, providing detailed supporting documentation and engaging in communication with the payer to secure appropriate reimbursement.

My approach to problem-solving in telehealth billing and coding is methodical and data-driven. I utilize a structured process:

1. Identify the problem: Clearly define the issue—is it a coding error, a system glitch, or a payer issue?
2. Gather information: Collect all relevant data, including patient records, billing records, and payer guidelines.
3. Analyze the data: Use data analysis techniques to identify patterns and potential causes.
4. Develop solutions: Brainstorm and evaluate potential solutions.
5. Implement the solution: Test and implement the chosen solution, carefully monitoring the results.
6. Document the process: Maintain detailed records of the problem, the solution, and the outcome. This helps prevent future recurrences.

For example, if we consistently experience denials for a particular procedure, I might analyze the claim data to identify patterns, such as specific modifiers or diagnosis codes associated with the denials. This analysis can pinpoint the source of the problem and allow for targeted corrections.

In a fast-paced telehealth billing environment, effective prioritization is key. I use a combination of techniques to manage my workload:

• Prioritization Matrix: I categorize tasks based on urgency and importance (urgent/important, important/not urgent, etc.).
• Time Blocking: I allocate specific time blocks for different tasks, ensuring focused work periods.
• Task Management Software: I utilize tools like Asana or Trello to track progress, assign deadlines, and collaborate with team members.
• Regular Review: I regularly review my task list and adjust priorities based on changing circumstances.

This approach ensures that the most critical and time-sensitive tasks receive immediate attention while preventing burnout. I also proactively communicate potential delays or bottlenecks to prevent unexpected disruptions.

I have extensive experience training others in telehealth billing and coding procedures. My training approach is highly interactive and hands-on, focusing on practical application rather than just theory. I typically use a combination of methods:

• Classroom Training: I conduct interactive sessions covering coding guidelines, billing software, and payer-specific rules.
• On-the-Job Training: I provide personalized guidance and mentorship, observing team members and offering feedback.
• Online Resources: I develop and curate online resources, such as training manuals and video tutorials, to facilitate ongoing learning.
• Role-Playing: I use simulated scenarios to reinforce learning and build practical problem-solving skills.

For instance, I created a detailed training manual with step-by-step instructions and screenshots for navigating our billing software and submitting claims. I also regularly conduct Q&A sessions to address any challenges faced by the team members. This multi-faceted approach helps ensure that everyone is well-equipped to handle the complexities of telehealth billing.