Healthcare business consultant with more than 30 years of experience in medical practice management, revenue cycle management, PM/EHR implementation, and business development

Aimee Heckman, CPB, CPPM

, we discussed the challenges surrounding 

getting paid for telehealth this year and beyond

. This is an essential issue for independent practices, but it’s not the only one. New legislation, as well as changes in patient expectations, present a host of challenges and opportunities for getting paid for service this year.

E/M Office and Outpatient Guidelines Changes

For the first time in more than two decades, the AMA has revised the guidelines for office and outpatient visit evaluation and management (E/M) codes. It’s been a long time coming—effective this year, CMS has aligned E/M coding with the changes adopted by the AMA. For many providers, this means an increase in their revenue because they will finally be compensated for time spent in activities related to patient care that were previously not easily accounted for in the guidelines.

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Clinicians are now able to choose codes for their new and established visits based on either time or medical decision making. Unlike the previous time-based options, which required that 50% or greater of the visit be spent on counseling and coordination of care, the new guidelines include total time spent by the provider related to the visit. This time includes non-face-to-face time spent on the day of the visit performing activities such as reviewing tests, obtaining or reviewing history, performing exams or evaluations, counseling and education of the patient/family/caregiver, and ordering medications, tests or procedures. It also includes communicating with other healthcare professionals and documenting clinical information in the health record, independently interpreting results, and communicating to the patient/family/caregiver, and care coordination.

With the new E/M guidelines, clinicians can now account for all the time they have been spending doing most of these things. One important note is that providers must document the time spent on these activities in their medical records to justify the coding in the event of an audit. This should be relatively easy to accomplish through updates to templates in most EHR systems.

The other option for determining the level of E/M code is medical decision making (MDM). This is not a new concept, as MDM has been one of three elements in determining the level of code for E/M services. The new guidelines, however, allow clinicians to choose MDM based on two of three elements: number and complexity of problems addressed, amount and/or complexity of data to be analyzed, and risk of complications and/or morbidity or mortality of patient management. The AMA has provided a Code and Guideline Changes document on the new requirements including an Elements of Medical Decision-Making table that illustrates the new coding guidelines.

Remote Patient Monitoring Can Improve Outcomes

Patients with chronic conditions who are following their care plan and managing their symptoms don’t always need an in-person visit. In addition to telehealth, adding remote patient monitoring for blood pressure and diabetes can help keep more chronic patients on track with their care plan. Studies have shown that patients who use remote monitoring devices are more consistent with taking their readings, and reporting to the provider is automated so it is easier to see changes in a patient’s condition that might require an in-person visit or an adjustment to medications.

New technologies and service offerings allow providers to engage a third-party vendor to provide remote monitoring equipment and train patients on how to use their systems to monitor and transmit their results. In many cases, the vendor provides monitoring of the patient to ensure compliance. By utilizing a third-party vendor for remote patient monitoring, an independent practice can free up staff time spent reviewing patient logs and can ensure better compliance for patients who may be prone to skip readings.

RVUs: The basics of physician compensation

It’s worth mentioning that new surprise billing legislation has been passed that will prohibit providers from sending bills for out-of-pocket expenses that a patient could not have reasonably predicted. This primarily applies to services rendered in hospitals, particularly in emergency situations where not all providers are in the patient’s insurance network. Previously, the patient might receive a bill for the full amount of each (out-of-network) provider’s standard rate.

While the surprise billing guidelines likely will not directly impact many independent practices, they may have a positive effect in that patients will not find themselves crushed under unexpected, astronomical charges for healthcare. This new legislation will go into effect January 2022 and it would be worth it for a provider to review both the federal law and the laws specific to their state to determine how it might impact the practice.

The bottom line is that things are changing rapidly, and independent practices need to stay updated and aware if they are to avoid pitfalls and take advantage of new possibilities for getting paid today.

Terri Joy, MBA, CPC, CGSC, COC, CPC-I, is a billing subject matter expert at Kareo, with over 20

years’ experience in physician billing and revenue cycle management.

Aimee Heckman, CPB, CPPM, is a healthcare business consultant with more than 30 years of experience in medical practice management, revenue cycle management, PM/EHR implementation, and business development. More information can be found at

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New legislation, as well as changes in patient expectations, present a host of challenges and opportunities for getting paid for service this year.

Getting Paid Today: Challenges and opportunities for independent practices

In a very real sense, telehealth has been responsible for enabling independent healthcare practices to stay in practice and continue to provide care to their communities during the pandemic. A survey conducted by Kareo in June 2020 found that 75% of independent practice respondents reported a decline in patient volumes, indicating a severe threat to their ability to stay in business. However, a more recent December 2020 survey showed that despite this initial decline, independent practices were showing signs of recovery. For 22% of respondents, their patient volumes had returned to the same level as they were in December 2019, before the pandemic. For 29%, their patient volumes had even increased over the same period the previous year.

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This recovery can be attributed to a great extent to telehealth. At that same time, one could say that the adoption of telehealth by independent practices was propelled forward five years by the pandemic. In 2019, a Kareo report showed the adoption rate of telehealth at only 22%. That 

changed quickly as a survey conducted soon after the initial stay-at-home orders went into place in March showed that the rate of telehealth usage nearly doubled to 41%, and then skyrocketed to 77% in a survey conducted in June 2020. By December 2020, a follow up survey showed that telehealth was up by 80% – telehealth had clearly gone mainstream.

However, the flourishing of telehealth in 2020 was driven not just by necessity, but also by a significant loosening of governmental regulations and reimbursement requirements by payors. Waivers were granted during the public health emergency that allowed the use of traditionally non-compliant communications platforms, such as FaceTime and other consumer-level technologies. Practices have been able to grab most any technology and expect to get paid for the appointment. But today, both states and payors are already changing their rules and laws rapidly. A good first step for many practices is to wean themselves away from non-compliant communications to immediate implementation of aHIPAA-compliant telehealth solution that will be essential when the public health emergency is terminated.

To ensure that you will continue to be paid for your telehealth services, here are three best practices you should be aware of:

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1. Check to see if your state has proposed or passed legislation requiring insurance companies to cover telehealth.

Your local medical societies are often a good source of this information. Several states are already passing regulations regarding telehealth reimbursement requirements. Determine exactly what the regulations are in your state, who it affects, and when it goes into effect.

2. Closely monitor bulletins and announcements regarding telehealth from any insurance payors your practice accepts.

Payor policies are changing rapidly and unexpectedly. Do not assume that any policies that applied in 2020 will continue. Make monitoring of payor policies at least a monthly discipline.

When you verify that a particular patient’s insurance accepts telehealth, determine if the coverage specifies the use of the payor’s approved telehealth vendor only. In that case, appointments conducted on the practice’s telehealth platform may not be covered. In some cases, state telehealth regulations might specify that the telehealth appointment must be allowed to be conducted with the patient’s regular provider, which could supersede the payor’s requirements. However, even if your state has such a requirement, be extra careful in 2021. There may be a gap between the implementation of state requirements and the provider contracts and policies that would postpone application of the state requirements until 2022.

What many providers and their staff may also not realize is that ERISA rules override state laws regarding employer-based plans, so it is not safe to assume that a health plan covers telehealth services under the state mandated guidelines. Always confirm the specific plan benefits for telehealth and instruct billing staff to watch for payment discrepancies as the situation with the public health emergency evolves.

3. Update and clarify your practice’s financial policy regarding collection of co-pays for telehealth services.

To provide much-needed care during the pandemic, policies regarding collection of co-pays became very lax in many healthcare practices. Now is the time to remedy that. A clearly stated practice of collecting patient payments before service, just as would be done if the patient came into the office, should be in place and practices should not hesitate to reschedule appointments if payments aren’t made. A procedure to maintain a credit card on file simplifies timely payments. Make sure patients receive a copy of your policies so they know what and how much to expect to pay. When patients are unclear as to the amount owed, they tend to put off paying their healthcare bills.

There’s no doubt that telehealth is here to stay. Both practitioners and patients have discovered that telehealth is a viable approach to healthcare delivery. In fact, patients love the convenience of telehealth and now expect it as a delivery option. If a practice doesn’t offer telehealth, patients may go elsewhere. Therefore, it’s critical that independent practices stop considering telehealth as a fortunate stopgap and make sure that they are laying the groundwork to make telehealth a robust part of their care delivery – and their bottom line.

It’s critical that independent practices make sure that they are laying the groundwork to make telehealth a robust part of their care delivery and their bottom line.