Health Information Compliance Alert

To ensure that your telehealth and phone visits stack up against provider audits, ensure that the following documentation points are included in your records, advises Scott Kraft, CPC, CPMA, senior compliance consultant with Doctors Management.

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,” Kraft said.

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.

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