EM Coding Alert

In the previous article, we discussed some of the general principles behind documentation for telehealth services that were discussed in the Doctors Management July 16 webinar “Audit Analytics: Post-Pandemic Preparation.”

In this article we thought we’d get a little more specific about that documentation and provide some concrete suggestions to ensure that your telehealth and phone visits stack up against provider audits.

For Audio-Only Visits (Where 99441-99443 Are Typically Reported)

• Documentation that the patient consented to an audio-only visit.
• Documentation of the type of visit, and clear documentation that the visit was audio only.
• Detail of what was discussed.
• Specific documentation of time spent. “If there’s no time documented for an audio encounter, there’s nothing to support because these are all time-driven codes,” says Scott Kraft, CPC, CPMA, senior compliance consultant with Doctors Management.

Keep in mind: Only direct communication time with the patient counts; do not apply the concept of total time spent throughout the day associated with the service.

For Audio and Video Visits (Where the Face-to-Face E/M Codes Are Typically Reported)

• Documentation of patient consent.
• Documentation of the type of visit and a statement identifying that the visit was conducted via both audio and video. This may seem obvious to the provider, but not to the person reading the note. “In some cases, I can’t even tell a telehealth visit was performed, except I notice the 95 modifier [Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system] appended, but that doesn’t make it clear that the visit took place via audio and video,” noted Kraft.
• History and exam that were taken during the visit, as applicable. “The history and exam will not necessarily be used to count elements, but the documentation should reflect what was captured and observed during the visit,” Kraft counseled.

• Documentation of MDM, and, if you aim to bill based on time, the specific amount of time. “Time ranges can’t be used. Mention the exact amount of time,” Kraft said.

  Remember: According to CMS, “when billing or office/ outpatient E/M services furnished via telehealth, the E/M level selection can be based on Medical decision making (MDM) or time.” “When selecting based on time,” CMS goes on to say, “on an interim basis for the duration of the PHE for the COVID-19 pandemic, practitioners should use the typical time as specified in the CPT® code descriptor for purposes of level selection” (Source: www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf).

  Note: Some commercial payers may have different reporting requirements. Don’t forget to check with them for their telehealth guidelines.