EM Coding Alert

“Although we associate fraud with intent, ‘intent’ is something that’s a perception,” said Scott Kraft, CPC, CPMA, senior compliance consultant with Doctors Management, during the webinar. In fact, he adds, someone may look at your records and find that your documentation skills are “broadly incompetent” due to lack of training, but the reviewer may perceive that as intent.

One thing Kraft has seen during early audit work is that there is quite a bit of confusion between audio-only visits and those visits that include both audio and video. “Most relaxed rules have given you a much wider berth for video communication than what telehealth previously had,” he said. For example, there are things like FaceTime or interactive services that haven’t been cleared security-wise that are fine during the length of the PHE. However, the burden of documentation lands on the provider to state whether they performed an audio visit or if it included both audio and video, and Kraft knows from Medicare encounters that there may be situations where patients may not know how to do an interactive video call.

“I’ve already seen dozens of telehealth encounters, in the limited audit work I’ve done in this area, where I have no idea based on the documentation if it was audio or video,” he said. “But in the descriptions for the codes 99201-99215 [Office or other outpatient visit for the evaluation and management of a new/established patient …] that are typically used for telehealth, the face-to-face requirement still applies; it just has to be done by video.”

When audio is used without video, the right codes to report are 99441-99443 (Telephone evaluation and management service …), Kraft noted. “But the burden falls on the provider to make sure it’s clear in the documentation whether the visit is taking place from an audio versus video perspective.”

Practices should always include a statement in the note that makes clear that the visit took place via audio and video communication when applicable, “and I encourage people to document whether it’s via FaceTime or some other service, but it should be clear how the visit was done to ensure that when reviewed, it’s clear that it was a telehealth service and not a telephone service.”

Billing Based on Time? Document That Clearly

“One thing that was done that works in favor of the providers is that during the PHE, the E/M service level can be selected by medical decision making [MDM] or time, and time is defined as all time associated with the E/M service,” Kraft said. This is due to CMS adopting the 2021 rule for time documentation rather than the current regulations, which require you to ensure that 50 percent of the visit is spent on counseling or coordination of care.

“So when we look at the documentation and we see time documented, we aren’t looking at what we think of as the current traditional time rule where more than half is spent on counseling/coordination of care — we really only need the total typical service time that should be aligned with the E/M code.”

When he audits, Kraft looks at time documented and the MDM, and asks himself which coding method most favors the provider. “So, I may see documentation that states the visit lasted 10 minutes, which would align with 99212, but the MDM supports 99213, so in that scenario I’m not constrained to 99212 because it took 10 minutes,” he says.

He also reminds practices that the same amount of time can’t be documented for every patient. “Time should be unique and specific to each patient encounter,” Kraft said. “When every single 99214 says 25 minutes for telehealth, that’s concerning. So, we do want to make sure time is accurate for each patient.”

In addition, make sure your documentation doesn’t include statements for services that can only be performed during in-person visits. “I see a lot of telehealth visits right now that have documented exams for things that I would like the physician to demonstrate how they managed to perform them,” Kraft said. “You aren’t palpating a patient, for example.”

“I see situations where the parent or guardian is touching the patient and describing it and that may be clinically helpful in terms of treatment, but I don’t consider that to be part of the physician’s exam to hear a parent say the patient is ‘warm,’” Kraft says. “It’s up to the physician’s clinical judgement to render findings based on what comes within the exam.”